Columbia  Wini\)tviit]^ 

in  tfje  €itp  oi  i^eto  gor& 
College  of  Ij^iy^itiam  anb  ^urseons; 


3@r.  Walter  ??•  SFamesf 


Digitized  by  tine  Internet  Archive 

in  2010  witin  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesofrespirOOwaug 


The  Diseases  of  the 
Respiratory  Organs, 

Acute  and  Chronic. 


Arranged  in  Two  Parts* 


By  WILLIAM  F.  WAUGH,  A.M.,  M.D., 

PROFESSOR     OF     PRACTICE   AND     CLINICAL    MEDICINE, 
ILLINOIS   MEDICAL   COLLEGE,  ETC. 


CHICAGO : 

G.  P.  ENGELHARD  &  COMPANY, 
190 1. 


PART  I 

Copyrighted  by 

G.  P.  Engelhard  &  Co., 

1 901. 


PART  II 

Copyrighted  by 

Alkaloidal  Publishing  Co. 

1901. 


PREFACE. 

This  book  has  been  prepared  because  of  the 
writer's  belief  that  the  treatment  of  acute  affec- 
tions of  the  respiratory  organs  has  progressed  far 
beyond  that  given  in  the  textbooks  on  Practice. 
Most  of  the  new  material  is  dispersed  through  nu- 
merous periodicals,  from  which  it  is  not  always 
rescued  by  the  compilers  of  annual  and  other  ab- 
stracts. The  methods  of  treatment  herein  advo- 
cated are  based  upon  the  author's  conception  of  the 
role  played  in  acute  inflammations  by  the  vasomo- 
tor nerves,  and  his  belief  that  the  future  of  scien- 
tific therapeutics  lies  in  the  study  of  such 
pathologic  states,  and  the  influence  of  drugs  upon 
them,  rather  than  in  the  consideration  of  these 
maladies  as  pathologic  entities.  There  is  this  to  be 
credited  further  to  this  conception  of  therapeutics, 
that  it  points  to  the  active  intervention  of  the  phy- 
sician at  a  period  in  the  history  of  the  case  not 
only  before  the  time  when  the  diagnosis  is  usually 
made,  but  even  before  the  malady  has  become  fixed 
in  the  tissues.  That  remedial  agents  will  exert  an 
active  influence  at  this  time  is  no  more  impossible 
than  that  disease-processes  are  then  at  work;  that 
the  efficiency  of  these  agents  is  far  greater  than 
when  the  damage  has  been  perpetrated  is  not  diffi- 
cult of  belief. 


PREFACE. 


This  subject  is  but  in  its  formative  state,  and  is 
by  no  means  presented  as  a  finished  product.  It 
is  simply  a  bit  of  the  scaffolding,  of  which  not  a 
stick  may  be  retained  in  the  final  structure. 

In  preparing  the  book  the  author  has  availed 
himself  of  useful  materials  wherever  he  found 
them,  and  has  not  attempted  to  credit  these  to 
their  various  sources,  not  always  possible  to  trace. 
But  he  must  call  attention  to  the  free  use  he  has 
made  of  Anders'  fine  textbook  on  Practice,  upon 
which  he  has  drawn  freely,  especially  in  the  part 
devoted  to  pathology.  William  F.  Waugh. 

Chicago,  April,  1901. 


CONTENTS. 

CHAPTER.  PAGE. 

I.     Hay   Fever    1 1 

II.     Acute  Laryngeal  Catarrh 14 

III.  Acute  Coryza   16 

IV.  Laryngismus  Stridulus   21 

V.     Membranous  Croup   23 

VI.     Acute  Bronchitis 29 

VII.     Fibrinous  Bronchitis  39 

VIII.     Asthma    41 

IX.     Pulmonary  Hyperemia   46 

X,     Pulmonary  Edema   48 

XI.     Hemoptysis   50 

XII.     Pulmonary  Apoplexy 57 

XIII.  Pulmonary  Embolism   58 

XIV.  Broncho-Pneumonia  60 

XV.     Pulmonary  Gangrene    65 

XVI.     Pulmonary  Abscess   67 

XVII.     Pleurisy 69 

XVIII.     Empyema   82 

XIX.     Pneumothorax    86 

XX.     Pneumonia 89 

XXI.     Influenza    114 

XXII.     Acute  Phthisis  123 

XXIIL     Chronic  Bronchitis  I37 

XXIV.    Bronchiectasis    149 

XXV.     Bronchial  Stenosis   153 


The  diseases  of  the  respiratory  organs. 

XXVI.  Pulmonary  Congestion   154 

XXVII.  Chronic  Pneumonia  157 

XXVIII.  Atelectasis   160 

XXIX.  Emphysema  162 

XXX.  Pneumonokoniosis 166 

XXXI.  Pulmonary  Cancer  168 

XXXII.  Pulmonary  Hydatids  170 

XXXIII.  Chronic  Pleurisy 171 

XXXIV.  Hydrothorax    173 

XXXV.  Chronic  Phthisis    174 

XXXVI.  Camp  and  Sanatorium  Treatment 202 

XXXVII.  Management  of  Predisposed 213 


PART  I. 

ACUTE  RESPIRATORY  DISEASES. 


CHAPTER   I. 
HAY-FEVER. 

Definition. — This  is  a  form  of  acute  nasal  ca- 
tarrh occurring  in  the  fall  or  spring,  each  victim 
expecting  the  onset  on  a  special  date,  or  when  some 
particular  plant  is  discharging  its  pollen.  The 
golden-rod  is  especially  obnoxious.  The  affection 
is  more  common  among  men,  young  or  middle- 
aged,  usually  of  wealth  and  leisure.  This  indi- 
cates a  relationship  with  uricemia,  from  full  diet 
and  lack  of  corresponding  exercise.  Hypertro- 
phies of  the  nasal  mucosa  are  frequently  present. 

Symptoms. — The  attacks  begin  abruptly,  with 
symptoms  of  acute  catarrh  of  the  nose,  eyes  and 
pharynx.  The  discharge  usually  remains  clear. 
The  affection  is  aggravated  by  exposure  to  the  open 
air.  Sometimes  the  catarrh  extends  to  the  pulmo- 
nary tract.  The  symptoms  persist  until  the  flow- 
ering season  of  the  obnoxious  plant  is  over  or  until 
frost. 

Diagnosis. — Hay-fever  is  distinguished  by  its 
recurrence  with  each  season,  the  persistence  of  the 
first-stage  svmptoms,  and  its  obstinacy  in  resist- 
ing treatment  effective  against  ordinary  catarrh. 

Prognosis. — As  regards  a  permanent  cure  the 
chances  are  not  good. 


12  THE   DISEASES    OF   THE   RESPIRATORY    ORGANS. 

Treatment. — The  Hay-Fever  Association  re- 
ports the  successful  treatment  still  undiscovered. 
Patients  must  get  out  of  reach  of  the  causative 
element,  and  immunity  is  found  by  some  at  the 
seaside,  by  others  in  elevated  mountainous  resorts, 
by  others  in  northern  latitudes.  Petoskey,  in 
Northern  Michigan,  is  a  favorite  resort  for  Chi- 
cago's hay-fever  sufferers. 

The  chances  for  relief  are  better  if  hypertrophy 
or  other  removable  disease  of  the  nasal  mucosa  is 
found.  In  some  instances  the  cure  of  such  local 
disease  has  been  followed  by  a  cessation  of  the  at- 
tacks, the  pollen  no  longer  finding  a  congenial 
habitat.  The  application  of  formalin  or  chromic 
acid,  to  harden  the  spongy  tissues,  has  been  tried 
with  some  success.  Begin  with  a  half  per  cent 
solution  and  increase  until  the  desired  effect  is  se- 
cured. The  objection  to  all  irritant  applications 
is  that  they  require  preliminary  cocainization, 
with  the  great  danger  of  the  formation  of  a  drug- 
habit,  the  most  disastrous  of  all  that  afflict  hu- 
manity. It  is  better  to  wash  out  the  nostrils  with 
mild  alkaline  solutions,  such  as  a  quart  of  warm 
water  with  a  drachm  of  soda  or  salt,  and  an  ounce 
of  hamamelis  distillate,  and  then  apply  a  protec* 
tive  spray  of  fluid  petrolatum. 

Some  success  has  ensued  from  the  administra- 
tion of  strychnine  arsenate,  two  milligrams  (gr. 
1-30),  every  four  hours,  increased  until  the  effect 


HAY-FEVER.  18 

of  the  strychnine  is  manifested.  This  may  re- 
quire four  times  the  above  dose,  or  more.  The 
astringent  effect  of  suprarenal  extract  has  been 
utilized  with  some  success ;  three  decigrams  (gr.  v) 
three  or  four  times  a  day.  Atropine,  one-tenth 
milligram  (gr.  1-500)  every  half-hour  till  the 
secretion  is  checked,  is  the  best  palliative,  and  has 
no  danger  back  of  it  like  cocaine.  Possibly  the  at- 
tack could  be  prevented  if  the  prospective  patient 
wore  a  respirator  charged  with  antiseptics  or 
glycerin  to  prevent  the  access  of  the  pollen. 


CHAPTER  II. 
ACUTE  LARYNGEAL  CATARRH. 

Etiology. — The  causes  are  those  of  acute  ca- 
tarrhs, exposure  to  cold  and  wet,  inhalation  of  irri- 
tants, and  extension  from  the  bronchi  below,  the 
pharynx  and  nose  above.  Measles,  whooping-cough 
and  other  acute  infections  are  attended  by  laryn- 
gitis. Smoking  and  alcohol-drinking  occasion  an 
increased  liability  to  it. 

Symptoms. — Cough,  hoarseness,  pain  on  en- 
deavoring to  talk,  stiffness  and  sometimes  pain  in 
the  larynx,  and  irritation  as  if  a  crumb  had  lodged 
in  the  larynx,  are  characteristic  symptoms.  The 
cough  is  dry,  wheezing  and  incessant.  Swallowing 
may  be  painful.  Dyspnea  follows  if  there  is 
swelling  of  the  glottis.  There  may  be  a  little  fever, 
the  pulse  slightly  accelerated.  The  laryngoscope 
shows  the  mucous  membrane  red  and  swollen,  dry, 
or  covered  with  a  sticky  mucus. 

Diagnosis. — ^Dry  cough,  and  interference  with 
the  function  of  the  larjrax,  phonation,  are  char- 
acteristic. The  laryngoscope  reveals  the  location 
and  extent  of  the  affection. 

Treatment. — Confine  the  patient  to  a  well- 
warmed  room,  and  let  him  inhale  steam  as  fre- 
quently as  possible.     Speech  must  be  forbidden 


ACUTE  LARYNGEAL  CATARRH.  15 

Apply  a  cold  compress  to  the  neck  over  the  larynx. 
Subdue  the  fever  with  aconitine  amorphous,  half 
a  milligram  (gr.  1-134)  every  ten  to  thirty  min- 
utes for  an  adult,  and  stimulate  secretion  by  apo- 
morphine,  a  milligram  (gr.  1-67)  at  the  same 
intervals,  suspending  it  on  the  occurrence  of  nau- 
sea. ISTo  other  remedy  equals  steam  for  the  cough, 
and  it  is  unnecessary  to  add  any  medicament 
like  benzoin.  If  the  irritative  cough  persists  give 
syrup  of  yerba  santa,  a  teaspoonful  every  hour  or 
two.  Great  care  should  be  exercised  when  the 
patient  goes  out  into  the  cold  air,  and  a  respirator 
could  be  worn  with  advantage,  especially  if  the  pa- 
tient does  not  breathe  exclusively  through  the  nose. 


CHAPTER  III. 

ACUTE  CORYZA. 

An  acute  inflammation  of  the  mucous  membrane 
of  the  nose,  sometimes  extending  to  the  throat, 
larynx,  bronchi,  less  frequently  to  the  ears,  or  the 
sinuses  opening  into  the  nose. 

Etiology. — There  is  a  predisposition  to  colds 
in  the  head,  especially  in  the  subjects  of  chronic 
nasal  catarrh,  so  that  most  attacks  are  simply 
acute  exacerbations  of  the  chronic  affection.  The 
nasal  mucosa  then  appears  to  be  the  "locus  rests- 
tentiae  minoris/'  and  it  has  been  held  to  be  a  safe- 
guard, as  colds  settle  here  in  preference  to  more 
dangerous  localities. 

The  exciting  causes  are  exposure  to  cold  or  wet, 
over-fatigue,  excessive  drinking,  over-eating,  the 
inhalation  of  irritant  dust  or  gas,  extension  from 
pharyngeal  or  palatal  catarrh.  The  epidemic  form 
is  probably  due  to  the  influenzal  bacillus,  or  pos- 
sibly at  times  to  some  other  micro-organism. 

Symptoms. — The  attack  often  begins  with  itch- 
ing in  the  soft  palate,  or  burning  in  some  part 
of  the  naso-pharyngeal  mucosa,  chilliness,  tickling, 
sneezing,  and  the  discharge  of  a  watery  fluid  that 
irritates  the  membrane  and  skin  with  which  it 
comes  in  contact,  excoriating  the  upper  lip  and 


ACVTE   CORYZA.  17 

margin  of  the  anterior  nares,  and  extending  the 
inflammation.  Headache,  weakness,  aching  of  the 
muscles  and  tendency  to  sweating  from  relaxation 
of  the  cutaneous  tension,  are  commonly  present. 
The  temperature  rises  to  100°-104°  F.,  the  pulse  is 
accelerated  but  compressible,  thirst  is  felt,  the  appe- 
tite may  be  good  or  impaired,  the  bowels  consti- 
pated. The  nasal  passages  are  closed  by  swelling, 
but  when  the  patient  lies  down  the  top  nostril 
opens,  the  passage  of  air  along  it  causing  burning. 
When  the  patient  turns  over  to  the  other  side,  in 
a  few  moments  the  under  nostril  closes  and  the 
upper  one  opens.  Taste  and  smell  are  lost.  Herpes 
around  the  anterior  nares  or  lips  is  common.  The 
secretion  becomes  turbid,  purulent,  and  large  quan- 
tities of  thick  yellow  muco-pus  are  discharged, 
sometimes  tinged  with  blood.  The  acute  symptoms 
subside  within  a  week,  the  discharge  gradually 
drying  up. 

Lachrymation  and  conjunctivitis  indicate  exten- 
sion to  the  eyes,  deafness  and  earache  to  the  middle 
ear  by  the  eustachian  tube,  cough  and  hoarseness 
to  the  larynx,  etc.  A  rare  extension  is  to  the 
frontal  sinuses.  Twice  I  have  witnessed  this,  in 
both  instances  delirium  and  coma  supervening, 
which  continued  until  calomel  had  been  given  to 
salivation.  In  a  third  case  the  symptoms  were  so 
alarming  that  I  trephined  the  right  frontal  sinus, 
giving  exit  to  offensive  pus,  with  immediate  relief. 


18  THE   DISEASES    OF   THE   RESPIRATORY    ORGANS. 

Diagnosis. — Influenza  is  distinguished  by  the 
greater  severity  of  the  symptoms,  especially  the 
pain  and  debility,  by  its  epidemic  prevalence,  and 
by  the  presence  of  the  characteristic  micro-organ- 
isms. 

Measles  may  be  suspected  if  the  patient  is  liable 
and  has  been  exposed  to  this  infection,  by  the 
accompanying  catarrh  of  the  eyes,  pharynx,  larynx 
and  bronchi,  and  by  the  crimson,  punctate  eruption 
on  the  pharynx;  also  the  higher  fever  and  the 
'^goose-like"  odor. 

Prognosis. — The  gravity  lies  in  the  possible  ex- 
tension of  the  affection  to  the  lungs  or  the  frontal 
sinuses ;  young,  weakly  infants  and  feeble  old  men 
being  in  some  danger.  In  ordinary  cases  the  pa- 
tient may  be  promised  return  to  his  business  in  a 
week,  though  neglect  or  fresh  infection  may  pro- 
long the  attack  or  extend  the  malady. 

Treatment. — There  are  several  methods  of 
breaking  up  a  cold  at  the  outset.  The  most 
effective  is  this:  Clear  out  the  bowels  with  a 
brisk  purge,  adding  an  ipecacuanha  emetic  if  the 
attack  is  due  to  over-eating;  give 

Camphor six  centigrams  (gr.  1) 

Quinine  sulphate  .six  centigrams  (gr.  1) 

Atropine  .  .half  a  milligram  (gr.  1-134) 

repeated  every  hour  until  the  effect  of  the  latter 

is  manifested  by  some  dryness  of  the  mouth,  and 

then  whenever  this  has  subsided.    Forbid  all  food 


ACUTE   CORYZA.  19 

and  drink,  to  keep  the  blood-vessels  empty  and  al- 
low the  congested  capillaries  to  unload.  This  may 
be  aided  in  severe  attacks  by  pilocarpine,  a  milli- 
gram (gr.  1-67)  every  five  minutes  till  sweating 
freely;  or  by  amorphous  aconitine,  half  a  milli- 
gram (gr.  1-134)  every  five  to  fifteen  minutes,  till 
the  pulse  is  down  below  80  and  the  congestion  is 
subsiding. 

The  popular  remedy  of  hot  toddy  is  only  of 
benefit  by  dilating  the  cutaneous  capillaries,  and 
this  is  better  accomplished  by  atropine,  while  the 
sudorific  value  of  alcohol  is  far  below  that  of  pilo- 
carpine. All  methods  that  include  the  free  use  of 
beverages  of  any  sort  merely  aggravate  the  malady. 
Dover's  powder  gives  relief  and  may  break  up  the 
attack,  but  it  is  less  likely  to  do  so  than  the  com- 
bination recommended,  and  is  apt  to  be  followed  by 
severe  headache. 

Locally  the  most  satisfactory  remedy  is  petro- 
latum. In  many  persons  the  application  of  this 
substance  limits  the  spread  of  the  inflammation. 
The  best  method  is  to  melt  cosmoline  in  a  teaspoon, 
being  careful  not  to  get  it  too  hot,  and  pour  into 
the  affected  nostril ;  repeating  as  soon  as  the  sneez- 
ing recommences. 

If  the  attack  has  become  established  relief  en- 
sues when  the  nose  is  washed  out  with  warm 
salt  water,  containing  an  ounce  of  distilled  hama- 
melis  to  the  quart,  through  the  nasal  douche,  and 


20  THE   DISEASES    OF   THE    RESPIRATORY    ORGANS. 

spraying  with  fluid  albolene  or  vaseline.  The  in- 
halation of  steam  has  a  soothing  effect. 

The  patient  should  be  induced  if  possible  to  re- 
main in  a  warm  room,  the  air  kept  moist  by  evap- 
oration of  water.  As  the  attack  subsides  com- 
pound tincture  of  benzoin  may  be  added  to  the 
steam  inhaled,  or  benzoic  acid  to  the  petrolatum, 
one  to  two  grams  to  30  (gr.  x-xxx  to  the  ounce). 
Plain  fluid  petrolatum,  applied  with  an  albolene 
atomizer  to  the  nasal  mucosa,  is  a  powerful  pro- 
tective when  the  patient  has  to  go  out  in  the  cold  air. 

Neither  opiates  nor  cocaine  should  under  any 
circumstances  be  employed. 


CHAPTER  IV. 

LARYNGISMUS  STRIDULUS. 

Spasmodic  croup  occurs  most  frequently  in  chil- 
dren under  one  year  of  age ;  rarely  after  the  fifth 
year.  Kickets  frequently  coexists.  The  attacks 
may  be  induced  by  temper,  or  by  the  causes  of 
catarrh.  The  dyspnea  is  due  to  adductor  spasm 
from  reflex  causes.  Acute  catarrhal  laryngitis  may 
coexist. 

Symptoms. — A  sudden  attack  of  dyspnea  occurs, 
at  any  hour,  with  crowing  inspiration  and  cya- 
nosis. There  is  no  fever,  cough  nor  hoarseness. 
The  paroxysm  lasts  but  a  few  moments,  and 
if  severe  may  induce  general  convulsions. 
It  may  recur  at  any  hour,  several  times  in  the  same 
day.  The  attacks  are  commonly  termed  ^^kinks," 
and  the  child  believed  to  hold  the  breath  purposely 
when  crossed. 

Occurring  in  the  course  of  laryngeal  catarrh, 
the  child's  breathing  becomes  harsh,  it  coughs  and 
awakes  with  dyspnea,  the  attacks  continuing  for  an 
hour  or  more. 

Diagnosis. — Membranous  croup  is  continuous, 
not  paroxysmal,  and  occurs  in  older  children.  The 
characteristic  exudation  is  present  in  this  and  in 
diphtheria. 


22  THE    DISEASES    OF   THE    RESPIRATORY    ORGANS. 

Prognosis. — The  paroxysms  are  rarely  danger- 
oiis,  though  trying  to  the  mother. 

Treatment.  A  dash  of  cold  water  in  the  face 
is  effective,  or  cold  applied  to  the  neck  while  the 
child  is  in,  a  warm  bath.  Pass  the  finger  into  the 
fauces  and  raise  the  epiglottis.  If  the  child  can 
swallow,  a  small  dose  of  glonoin,  one-twentieth 
milligram  (gr.  1-1300),  repeated  every  five  min- 
ntes,  is  successful.  In  prolonged  spasms  this  may 
be  administered  hypodermically,  or  a  whiff  of  amyl 
given.  A  hypodermic  of  apomorphine,  half  a 
milligram  (gr.  1-134),  is  suitable  for  the  ca- 
tarrhal form,  occurring  in  older  children.  The 
treatment  advised  for  catarrhal  laryngitis  is  indi- 
cated in  such  cases.  A  sound  spanking  is  effective 
when  the  "kinF^  is  due  to  temper. 


CHAPTER  V. 

MEMBRANOUS  CROUP. 

Morell  Mackenzie  demolished  the  old  barriers 
between  diphtheria  and  membranous  croup.  He 
showed  that  the  differences  between  the  two  were 
simply  due  to  the  location,  diphtheria  occuring  in 
the  richly  vascular  structures  of  the  pharynx,  with 
abundant  glandular  connections,  croup  in  the 
thinner  membrane  stretched  over  the  lar}'ngeal 
cage,  with  no  lymphatics  except  Luschka's  gland. 
Croup  is  not  followed  by  paralysis,  simply  because 
the  little  patients  do  not  survive  to  reach  the 
paralytic  stage.  The  two  affections  occur  coinci- 
dentally,  and  run  into  each  other,  diphtheria 
extending  down  to  the  larynx,  the  croupous 
membrane  up  to  the  pharynx.  This  has  now 
become  the  prevailing  view,  especially  since  the 
boards  of  health,  wisely  choosing  the  safer  side, 
have  universally  required  the  reporting  of  all 
membranous  croup  as  diphtheria,  considering  it 
better  to  permit  no  possible  case  of  the  infectious 
malady  to  go  at  large. 

Nevertheless,  it  is  now  becoming  evident  that 
there  are  cases  of  membranous  croup  that  are  not 
laryngeal  diphtheria,  but  rather  the  highest  mani- 
festation of  the  inflammatory  process.     In  these 


m 


24  THE   DISEASES    OF    THE    RESPIRATORY    ORGNAS. 

the  micro-organism  of  diphtheria  cannot  be  found, 
and  their  causation  is  that  of  catarrh  rather  than 
of  diphtherial  infection.  There  is  no  sharply 
marked  line  of  difference  between  catarrhal  and 
membranous  croup,  but  cases  occur  so  near  the 
border  that  it  is  impossible  to  classify  them.  The 
older  works  gave  as  the  diagnostic  signs  of  the 
graver  malady  the  presence  of  fever  with  retrac- 
tion of  the  abdomen  on  inspiration,  but  such  cases 
occur,  even  necessitating  surgical  intervention, 
without  any  sign  of  membranous  formation. 

Membranous  croup  affects  children  between  the 
ages  of  two  and  seven,  rarely  outside  of  these 
limits.  Exposure  to  cold  winds  and  damp  is  the 
usual  exciting  cause.  "Croupy"  children  are 
usually  affected  by  catarrhal  laryngitis.  Those 
who  are  housed  too  closely,  in  superheated  flats, 
strangers  to  cold  baths,  rarely  allowed  to  breathe 
the  open  air  and  then  overloaded  with  clothing, 
are  the  usual  victims. 

The  affection  begins  usually  at  niglit,  with  a 
hoarse  croupy  cough,  with  dyspnea,  the  child 
struggling  for  breath.  The  difficulty  is  most 
marked  with  inspiration.  Examination  of  the 
throat  may  show  a  few  white  flecks  on  the  tonsils, 
which  increase  and  coalesce  into  a  thin,  white 
pellicle.  The  hoarseness  deepens  into  complete 
aphonia,  the  child  is  seen  to  cough,  not  heard. 
The  temperature  rises  to  101  to  103  degrees,  the 


MEMBRANOUS  CROUP.  25 

pulse    keeping    pace.      The  child  lies  quiet,    the 
breathing  being   sufficient    until   he    attempts  to 
move,   when    the    suffocative    paroxysm    at   once 
comes  on;  he  struggles   for   breath,   clutches   his 
mother,  and  finally  falls  back  exhausted,  when  a 
moment's  respite  ensues.      These   symptoms   con- 
tinue   until    morning,     when    some    moderation 
usually  occurs,  but  as  night  comes  on  the  struggle 
is  renewed.    The  obstacle  to  the  ingress  of  air  is  so 
marked  that  the  abdomen  is  retracted  on  inspira- 
tion  showing    a    boat-shaped    depression.      This 
marks  the  danger-point.     As  expiration  is  less 
obstructed  more  air  escapes   from  the  lung  than 
enters,  the  air  in  the  tract  becomes  rarefied,  and 
the   powerful  efforts   of  the   child  to   draw  air 
through  the  narrowed  chink  of  the  glottis  causes 
suction  as  of  an  air-pump  to  be  exerted  on  the  air- 
cells.     The  result  is  that  blood-serum  is  drawn 
through  the  delicate  walls,  and  begins  to  accumu- 
late in  the  air-cells  and  bronchioles.    Its  presence 
is  manifested  by  serous   rales,  at  first  fine  but 
growing  louder,  with  cyanosis  keeping  pace  with 
the  effusion.     The  struggles  of  the  child  become 
less  strenuous,  it  grows  quieter,  but  the  quiet  is 
that  of   approaching   death  from   carbonic   acid 
anesthesia.    This  is  the  usual  cause  of  death,  and 
if  surgical  intervention  be  delayed  till  now  it  will 
fail  to  save  the  patient's  life.    Even  if  death  does 
not  supervene  in  this  stage  there  would  ensue  an 


26  THE   DISEASES    OF    THE    RESPIRATORY    ORGANS. 

acute  broncho-pneumonia,  probably  resulting 
fatally. 

In  the  rare  cases  ending  in  recovery  the 
symptoms  are  prolonged  for  several  days,  until  the 
membrane  is  loosened  and  spit  or  vomited  up.  It 
may  be  reproduced,  but  this  is  rare.  In  one  case 
of  the  writer's  that  recovered,  a  strong  girl  near 
the  upper  age  limit,  with  a  larger  glottic  aperture 
than  usual,  paralysis  of  phomation  remained  for 
weeks. 

The  diagnosis  has  been  already  discussed. 
Catarrhal  croup  occurs  in  "croupy"  children,  with 
little  or  no  fever,  no  exudate  on  the  tonsils,  and 
yields  to  emetics  and  other  remedies.  In  diph- 
theria we  may  find  the  characteristic  micro-organ- 
isms, the  malady  begins  in  the  throat,  extends  by 
preference  up  to  the  nose,  the  glands  are  early 
involved  and  only  secondarily  attacks  the  larynx. 

The  prognosis  is  of  the  worst.  The  older 
writers  refuse  to  believe  recovery  from  true  croup 
possible. 

And  this  serves  to  illustrate  clearly  the  shock- 
ing barbarity  of  their  treatment.  If  the  child 
were  bound  to  die,  why  torture  it  with  emetics  of 
copper,  alum,  antimony,  turpeth,  etc.?  Why  not 
mercifully  let  it  die  in  peace  if  die  it  must  ?  One 
only  fragment  of  the  old  treatment  is  worthy  of 
retention — ^the  use  of  morphine.  It  will  be  noticed 
that  as  long  as  the  child  lies  quiet  the  respiration 


MEMBRANOUS   CROUP. 


2'r 


suffices  for  his  needs,  and  the  paroxysms  of 
dyspnea  occur  when  he  attempts  to  rise.  Give 
him  enough  morphine  to  keep  him  tranquil,  but 
carefully  avoid  narcotism,  which  is  here  certain 
death.  This  reduces  the  violence  of  the  paroxysms 
and  conserves  his  strength.  Then,  as  death  is  due 
to  the  pulmonary  edema  produced  by  suction,  just 
as  soon  as  retraction  of  the  abdomen  begins  to  be 
manifest  during  inspiration,  intubate.  Parents 
will  not  object  to  this  at  this  early  stage,  as  they 
are  apt  to  if  tracheotomy  is  suggested.  But  this 
matter  of  the  parent's  consent  has  been  grossly  ex- 
aggerated. The  physician  who  does  not  know  the 
necessity  for  such  operation,  and  knowing  this 
cannot  show  the  parents  that  necessity,  ought,  in 
pursuance  of  his  duty  as  a  saver  of  life,  to  turn 
the  case  over  to  some  one  of  sufficient  force  of 
character  to  compel  consent  to  the  duty.  Parents 
have  no  rights  that  involve  the  sacrifice  of  their 
child's  life. 

Within  a  few  years  a  new  remedy  for  mem- 
branous croup  has  been  advocated,  in  a  preparation 
known  as  iodized  lime.  It  is  not  a  chemical  iodide 
of  lime,  but  a  loose  combination  of  lime  and 
iodine,  the  effects  of  which  closely  resemble  those 
of  free  iodine.  In  fact,  I  look  upon  this  iodized 
lime  as  simply  a  handy  and  agreeable  mode  of 
administering  iodine.  The  dose  for  a  child  in  the 
croup  age  is  grain  %^  repeated  every  five,  ten  or 


28  THE   DISEASES    OF    THE    RESPIRATORY    ORGANS. 

fifteen  minutes,  until  the  croupal  symptoms  sub- 
side. And  this  they  do,  in  all  cases  that  have  come 
under  my  notice  during  the  last  two  years.  I 
have  many  letters  from  experienced  physicians 
who  report  almost  invariable  success  with  this  rem- 
edy. Its  use  has  also  confirmed  the  views  of  those 
who  believe  some  cases  of  membranous  croup  are 
not  diphtheritic,  for  when  the  malady  has  origi- 
nated in  the  pharynx  as  true  diphtheria  and  ex- 
tended then  to  the  larynx,  iodized  lime  has  not 
proved  effective,  while  calcium  sulphide  has  ex- 
erted the  same  powerful  control  as  over  manifesta- 
tions of  diphtheria,  when  pushed  to  full  satura- 
tion. Be  this  as  it  may,  the  subsidence  of  the 
symptoms  of  croup,  in  a  few  hours  while  calcium 
iodized  is  being  administered,  is  something  mar- 
velous to  one  accustomed  to  the  old  method  with 
its  invariably  fatal  ending.  Morphine  till  abdom- 
inal retraction  during  inspiration  occurs,  then  in- 
tubation, and  calcium  iodized  from  the  first,  given 
with  a  free  hand,  are  the  three  remedies  for  mem- 
branous croupi — and  the  only  three  whose  effects 
entitle  them  to  consideration. 


CHAPTER  VI. 

ACUTE  BRONCHITIS. 

Acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  trachea  and  bronchi.  The  af- 
fected membrane  is  red  and  puffy,  exuding  a  secre- 
tion at  first  watery,  then  cloudy,  opaque,  and  finally 
purulent,  gradually  drying  into  scabs  or  crusts. 
The  mucous  glands  swell,  the  epithelium  is  cast 
off,  the  submucous  layers  swell,  become  succulent, 
and  in  them  leucocytes  are  found  in  numbers  pro- 
portional to  the  severit}^  of  the  attack. 

Etiology. — The  causes  are  those  of  catarrhs; 
exposure  to^  cold  and  wet,  inhalation  of  irritant 
gases,  ammonia  or  ether,  vapor,  dust,  etc.  Usu- 
ally the  inflammation  begins  in  the  nose  or  throat 
and  extends  to  the  larynx,  trachea  and  bronchi. 
Pre-existing  chronic  catarrh  of  any  part  of  this 
mucous  tract  renders  the  individual  more  liable 
to  attacks.  The  aged  and  very  young,  the  feeble, 
uricemics,  eachectics,  those  who  are  too  much 
housed  up  in  superheated  flats  or  unused  to  ex- 
posure, are  apt  to  take  cold  readily.  Changes  in 
the  weather  cause  more  or  less  extensive  preva- 
lences, and  these  resemble  epidemics  if  they  are  not 
so  in  reality.  Many  infectious  maladies  number 
bronchitis  in  their  symptoms  or  sequels,  and  in 


30  THE    DISEASES    OF    THE    RESPIRATORY    ORGANS. 

nephritis  and  valvular  heart-disease  it  is  often 
present. 

Symptoms. — The  early  symptoms  are  those  of  a 
cold,  chilliness,  aching  muscles  and  head,  a  sense 
of  tightness  in  the  chest,  itching  in  the  larynx, 
dull  pain  under  the  sternum,  fever  usually  slight 
but  ranging  up  to  104°,  the  breathing  somewhat 
accelerated,  especially  in  children.  The  cough  is 
at  first  dry  and  irritative,  perhaps  severe  enough 
to  cause  soreness  at  the  insertions  of  the  dia- 
phragm, and  becomes  looser  as  the  attack  passes 
the  climax  and  the  sputa  become  purulent  and 
copious.  The  symptoms  closely  follow  those  of 
coryza  as  regards  the  secretion.  The  laryngoscope 
shows  the  mucous  membrane  to  be  red  and  swollen, 
later  covered  with  the  exudate.  Children  rarely 
suffer  an  initial  convulsion. 

The  hand  placed  upon  the  chest  detects  some 
fremitus.  Auscultation  discloses  sibilant  rales  or 
wheezing  in  the  early  stages,  gradually  replaced  by 
mucous  and  submucous  rales,  growing  larger  as 
the  secretion  becomes  freer,  with  sonorous  bronchi 
when  sticky  masses  adhere  to  the  sides  of  the  larger 
bronchi.  Earely  there  are  collections  of  secretion 
large  enough  to  cause  slight  dullness.  Coughing 
mav  alter  the  character  of  the  rales. 

Prognosis. — Bronchitis  is  dangerous  in  infants, 
aged  men  and  very  feeble,  cachectic  persons.  Ex- 
tension into  the  smallest  bronchi,  with  dyspnea. 


ACUTE  BRONCHITIS.  31 

sluggishness  or  cyanosis,  are  grave  symptoms 
in  such  cases.  Ordinarily  the  attack  subsides  in  a 
week,  the  cough  and  expectoration  continuing  in- 
definitely. Cachectic  patients  suffer  severely  and 
then  the  malady  tends  to  chronicity.  The  low  grade 
of  sensation  in  the  mucous  membrane  of  young 
infants  and  aged  persons  permits  the  accumula- 
tion of  secretion  to  a  dangerous  extent,  so  that 
such  patients  may  actually  drown  in  their  own 
sputa. 

Diagnosis. — The  slight  fever,  absence  of  crepi- 
tus and  dullness,  distinguish  bronchitis  from 
pneumonia.  The  former  is  bilateral.  Pleurisy 
has  a  history  of  acute  pain  on  inspiration,  dull- 
ness on  percussion,  with  bulging  intercostals  and 
loss  of  respiratory  movement.  In  broncho-pneu- 
monia the  rales  are  finer,  the  dyspnea  worse,  res- 
piration rapid,  fever  higher,  and  dullness  may  be 
found  in  spots.  Whooping-cough  may  be  inferred 
even  before  the  characteristic  whoop,  from  the 
cough  recurring  in  paroxysms  that  grow  more 
severe  as  the  catarrhal  stage  nears  its  end,  the 
cough  awaking  the  child  from  sleep  and  continuing 
until  vomiting  occurs.  Measles  presents  a  red, 
punctate  eruption  on  the  fauces  and  the  fever  is 
much  higher. 

Treatment. — As  with  nasal  catarrh,  it  is  pos- 
sible to  break  up  an  acute  bronchitis  if  seen  early. 
Confine  the  patient  to  a  warm,  equably  heated 


32  THE  DISEASES  OF   THE   RESPIRATORY    ORGANS- 

room,.ihe  air  moistened  by  water  continually  evap- 
orating in  it.  Administer  a  cathartic,  forbid  the 
use  of  fluids  as  strictly  as  possible,  and  give  one 
of  the  following: 

1.  Aconitine  amorphous  half  a  milligram  (gr. 
1-134),  atropine  J  milligram  (gr.  1-500),  mor- 
phine one  milligram  (gr.  1-67) ;  given  together, 
and  repeated  every  ten  minutes  until  the  physio- 
logic effect  of  one  or  other  of  the  constituents  be- 
gins to  be  felt.  Generally  it  is  the  atropine,  which 
manifests  its  commencing  toxic  action  by  dryness 
of  the  mouth.  As  soon  as  this  is  felt  the  fre- 
quency of  the  doses  must  be  diminished  to  one-half 
hour,  one  hour  or  two  hours,  the  object  being  to 
keep  up  the  effect  but  not  to  exceed  it.  This  has 
proved  most  effective  for  anemic,  slender  persons, 
but  should  not  be  used  for  uricemic  individuals. 

2.  Atropine  sulphate  J  milligram  (gr.  1-500), 
quinine  sulphate  one  centigram  (gr.  1-6),  camphor 
one  centigram  (gr.  1-6) ;  taken  together  every  ten 
minutes  till  the  atropine  effect  is  slightly  felt,  then 
less  frequently  so  as  to  keep  up  this  effect  b\it  not 
to  exceed  it;  that  is,  slight  dryness  of  the  mouth. 
In  some  individuals  the  first  atropine  effect  notice- 
able is  flushing  of  the  face  or  dilation  of  the  pu- 
pils, but  whatever  is  the  first  manifestation  the 
drug  should  not  be  pushed  beyond  it,  but  the  en- 
deavor made  to  hold  the  patient  just  at  that  point. 
This  is  good  treatment  for  plethoric,   over-feel. 


ACUTE  BRONXHITIS. 


88 


uricemic  patients,  and  those  who  have  weak  hearts 
or  a  tendency  to  constipation. 

3.  Pilocarpine  one  milligram  (gr.  1-67),  every 
five  minutes  until  sweating  or  salivation  begins, 
then  enough  to  sustain  the  action  just  at  this 
point.  This  is  especially  useful  in  stout  patients 
with  strong  hearts,  those  given  to  excessive  water- 
drinking,  free  sweaters. 

In  all  cases  it  is  necessary  to  forbid  fluids,  as,  if 
the  veins  are  gorged  with  fluid,  there  is  little  use  in 
trying  to  reduce  the  hyperemia  of  the  affected 
tract.  The  diet  should  for  the  same  reason  be 
spare.  Much  benefit  is  experienced  in  all  forms  of 
respiratory  catarrhs  by  keeping  the  air  of  the  room 
moistened  by  evaporating  water  in  it,  and  by  pro- 
longed inhalations  of  steam  frequently  repeated. 
The  mucus  is  softened  and  brought  up,  and  the 
inflamed  membrane  soothed  by  this  procedure. 

On  the  day  following,  the  attack  will  be  broken 
up  but  the  patient  relaxed,  and  in  favorable  con- 
dition to  contract  fresh  cold.  If  it  be  necessary 
that  he  should  go  out  this  relaxation  should  first 
be  removed  by  tonics,  such  as  brucine  or  berberine 
one  milligram  (gr.  1-67)  every  hour  or  two,  tiU  the 
toning  influence  is  manifest;  and  this  should  be 
sustained  for  several  days,  with  restriction  of  the 
quantity  of  food  and  drink,  these  being  non-stimu- 
lating in  quality. 

If  the  patient  is  not  seen  until  too  late  to  abort 


34  THE    DISEASES    OF    THE    RESPIRATORY    ORGANS. 

the  attack,  the  indication  is  to  hurry  it  through  itsj 
stages  as  rapidly  and  comfortably  as  possible.  The 
same  hygienic  and  dietary  rules  are  to  be  enjoined ; 
the  bowels  kept  somewhat  loose  by  saline  laxatives, 
the  hyperemia  moderated  by  the  judicious  admin- 
istration of  the  "dosimetric  triad/'  amorphous 
aconitine  J  milligram  (gr.  1-134),  digitalin  1  mil- 
ligram (gr.  1-67),  and  strychnine  arsenate  -J 
milligram  (gr.  1-134),  given  together  every 
half-hour  to  one  or  two  hours  as  required.  Only 
in  pronounced  plethorics  should  the  strychnine  be 
replaced  by  veratrine  in  like  doses.  Indeed,  the 
relaxation  usually  manifest  in  respiratory  catarrhs 
renders  the  tonics  advisable  in  most  cases  from 
the  first. 

To  promote  the  mucous  secretion  we  have  three 
excellent  remedies,  apomorphine,  lobelin  and  eme- 
tin.  The  first  is  the  most  powerful  and  speedy, 
and  suitable  to  severe  forms,  in  the  robust.  The 
dose  is  one  milligram  (gr.  1-67)  every  quarter- 
hour  till  faint  nausea  is  experienced,  then  less  fre- 
quently. Lobelin  is  a  powerful  stimulant  to  secre- 
tion, better  suited  to  croupy  and  asthmatic  or 
rather  dyspneal  forms.  Emetin  is  applicable  to 
children  and  weakly  patients,  where  the  more  pow- 
erfully depressing  remedies  might  be  dangerous 
if  given  recklessly.  The  doses  and  administration 
of  lobelin  and  of  emetin  are  the  same  as  of  apo- 


ACUTE  BRONCHITIS. 


B5 


morphine.  Either  should  be  continued  until  the 
mucous  secretion  is  loose,  thin  and  yellow. 

To  moderate  the  cough  and  bring  it  into  har- 
mony with  the  excretory  needs  of  the  patient  we 
have  likewise  three  excellent  remedies.  Codeine 
moderates  bronchial  irritability  more  directly  than 
any  other  drug,  with  less  interference  with  diges- 
tion. It  may  be  given  in  doses  of  one-fourth  to 
one  centigram  (gr.  1-24  to  1-6),  repeated  as  the 
case  demands.  The  second  remedy  is  the  inhala- 
tion of  steam,  of  which  I  have  already  spoken 
warmly.  The  third  is  patience.  To  one  who  has 
never  tried  it,  it  is  inconceivable  how  much  benefit 
accrues  in  the  irritative  stages  of  respiratory  ca- 
tarrhs from  persistently  restraining  the  impulse 
to  cough,  until  the  secretion  is  so  loose  that  slight 
effort  will  dislodge  it.  The  cough  is  largely  due 
to  the  inflammation,  consequently  is  useless,  and 
does  harm  by  straining  the  lungs. 

Mild  counter-irritation  to  the  chest  is  of  value, 
and  the  practitioner  may  choose  between  ammonia 
liniment,  mustard  mitigated  with  flour  or  mo- 
lasses, or  the  cold  compress  covered  thickly  with 
dry  warm  flannel.  Each  has  its  advocates  and  each 
is  of  value.  Cold  applications  have  proved  unser- 
viceable with  me  in  treating  uricemic,  plethoric 
persons,  especially  those  who  catch  cold  easily. 

As  the  attack  progresses  through  its  stages  it 
may  run  into  a  bronchorrhea,  with  free  serous  se- 


36  THE   DISEASES    OF    THE    RESPIRATORY    ORGANS. 

cretion.  It  is  probable  that  in  these  cases  the  pul- 
monary tract  has  been  invaded  by  a  swarm  of 
micro-organisms,  and  the  thin,  watery  secretion  is 
a  culture-flnid  of  these.  The  remedies  for  this 
condition  are  the  inhalation  or  atomization  of  tar- 
water,  and  cnbebs,  myrrh,  copaiba,  balsam  of  toln 
or  Peru,  benzoic  acid  and  its  salts.  Benzoic  acid 
and  cubebin,  a  centigram  (gr.  1-6)  each  every  ten 
to  sixty  minutes,  are  as  useful  as  any,  unless  it 
is  copaiba,  which  may  be  given  in  capsules,  three 
decigrams  (m.  v.)  every  two  hours  in  obstinate 
cases.  Strychnine,  two  milligrams  (gr.  1-30) 
every  two  to  four  hours,  is  also  advisable  to  in- 
crease the  tonicity  and  resistance  of  the  bronchial 
tissues.  The  diet  should  be  the  more  nutritious 
as  any  form  of  chronic  bronchitis  threatens  to  be- 
come established.  But  in  every  such  case  the  sputa 
should  be  repeatedly  examined  to  see  if  some  micro- 
bic  infection  has  not  occurred. 

If  the  catarrh  tends  to  become  dry,  with  scanty 
secretion,  it  may  require  stimulation  with  lobelin ; 
or  MurrelFs  advice  may  be  followed,  of  applying 
wine  of  ipecacuanha  locally  with  an  atomizer.  But 
if  dyspnea  attends,  with  irritative  cough  and  diffi- 
cult breathing,  the  sensory  respiratory  nerve  may 
be  sedated  by  atropine  one-eighth  milligram  (gr. 
1-500)  every  five  to  sixty  minutes  till  the  effect  is 
manifested.  This  will  be  hastened  by  combining 
glonoin  in  like  doses;  or  aspidospermine  may  be 


ACUTE    BRONCHITIS.  37 

employed^  half  a  centigram  (gr.  1-12),  every  five 
to  thirty  minutes,  or  iodoform,  a  centigram  (gr. 
1-6),  every  ten  minutes. 

In  elderly  patients  the  sensibility  of  the  respira- 
tory mucosa  is  slight,  the  tissues  relax,  and  the 
impulse  to  cough  is  not  felt.  Secretions  collect 
in  the  bronchi  until  the  patient  becomes  dull,  cool, 
cyanotic,  the  rales  may  be  heard  before  entering 
the  room,  and  the  patient  is  literally  drowning  in 
his  own  secretions.  The  remedy  is  an  emetic  of 
seidlitz  powder,  the  acid  solution  being  first  swal- 
lowed and  then  the  other,  which  will  empty  the 
stomach  more  quickly  than  any  other  emetic  and 
without  nausea  or  depression.  Follow  this  with 
sanguinarine  nitrate  a  milligram  (gr.  1-67)  every 
half  to  two  hours,  which  will  stimulate  sensation 
and  make  the  patient  cough  harder.  Squill,  senega, 
serpentaria  and  ammonia  act  similarly,  but  san- 
guinarine is  best. 

Infants  with  bronchitis  also  have  little  sensi- 
bility in  the  mucous  membrane,  and  care  must  be 
taken  that  the  secretion  is  raised.  Somnolence, 
blueness  about  the  lips,  pallor,  shallow  respiration, 
with  little  or  no  cough,  should  excite  uneasiness 
but  are  apt  to  be  overlooked  by  an  inexperienced 
mother.  An  emetic  will  rid  the  chest  of  mucus 
but  further  lowers  the  vitality.  Sanguinarine  in 
doses  appropriate  to  the  age  is  of  value,  also 
strychnine  pushed  to  the  physiologic  limit.    Place 


88  THE   DISEASES    OF    THE    RESPIRATORY    ORGANS. 

the  babe  in  a  hot  bath  and  dash  a  little  cold  water 
on  the  chest  to  excite  crjdng  and  fnll  respiration. 
If  emetics  are  given  it  should  only  be  at  night, 
that  the  respiratory  tract  may  be  freed  from  mucus 
before  the  parents  settle  for  sleep.  Opiates  should 
rarely  be  administered  to  infants  and  never  when 
subject  to  bronchitis.  Uricemics,  cachectics,  and 
persons  addicted  to  the  immoderate  use  of  bever- 
ages, are  especially  subject  to  bronchitis  and  other 
respiratory  catarrhs.  Ice-water  fiends  are  especially 
liable,  as  their  constant  perspiration  renders  them 
susceptible  to  every  draft.  This  should  be  taken 
into  account  in  seeking  to  lessen  the  vulnerability 
to  colds. 

Patients  should  be  restricted  to  their  rooms 
until  well  over  the  attack,  and  be  well  protected 
when  they  go  out. 


CHAPTER  VII. 

FIBRINOUS  BRONCHITIS. 

This  is  a  vrare  malady  in  which  fibrinous  casts 
of  the  bronchi  are  formed;,  and  expelled  with  diffi- 
culty. The  casts  form  molds  of  the  bronchial  tree. 
The  larger  ones  are  hollow.  The  epithelium  is 
shed  with  the  cast.  Anders  found  the  casts  identi- 
cal in  structure  with  ordinary  croupal  exudates. 

The  cause  is  not  known.  Streptococci  have 
been  found  in  the  casts.  The  malady  is  more  fre- 
quent in  males,  between  20  and  40,  in  spring, 
sometimes  seems  epidemic  and  may  be  hereditary. 
Tubercle,  pleurisy,  herpes,  impetigo  and  pemphi- 
gus have  been  noted  as  complications. 

The  rare  acute  form  begins  with  rigors,  followed 
by  fever,  dyspnea  and  severe  cough.  The  expulsion 
of  the  casts  may  be  followed  by  hemorrhage.  Free 
expectoration  gives  relief.  Urgent  dyspnea  and 
severe  dry  cough  may  precede  fatal  asphyxia. 

In  the  chronic  or  recurrent  form  paroxysms 
occur  at  intervals  of  a  week  to  a  year,  regular 
or  not,  the  onset  resembling  that  of  bronchitis, 
cough  severe  and  paroxysmal,  and  the  white  or 
gray  casts  appear.  They  consist  usually  of  mucin, 
some  of  fibrin. 

Physical  examination  shows  the  affected  lung  to 


40  FIBRINOUS   BRONCHITIS. 

be  airless ;  fremitus,  expansion  and  vesicular  mur- 
mur lessened,  percussion  normal  or  hyper-resonant, 
dull  if  collapsed,  the  ejection  of  the  casts  restor- 
ing the  normal  murmur. 

The  diagnosis  is  made  by  the  casts,  the  history 
differentiating  them  from  croup  and  diphtheria. 
Doubtful  cases  may  be  settled  by  a  search  for  the 
Klebs-Loeffler  bacillus  of  diphtheria. 

In  the  acute  form  the  prognosis  is  grave.  The 
chronic  form  is  obstinate  but  rarely  fatal. 

The  treatment  is  as  yet  unsettled.  Anders  ob- 
tained good  results  from  pilocarpine  in  one  case. 
Cyanosis  calls  for  emetics.  Steam  inhalations  and 
the  treatment  for  bronchitis  are  advised.  If  pilo- 
carpine is  given  it  should  be  in  doses  sufficient 
to  cause  free  sweating — "three  milligrams  (gr. 
1-20)  every  ten  to  thirty  minutes  till  effect. 
Potassium  bichromate  may  be  tried — two  milli- 
grams (gr.  1-30)  every  half-hour;  or  brown  iodized 
lime,  two  centigrams  (gr.  1-3)  every  five  minutes. 


CHAPTER  VIII. 
ASTHMA. 

A  neurosis,  consisting  of  paroxysms  of  spas- 
modic contraction  of  the  bronchioles,  causing  dysp- 
nea. This  is  pure  asthma,  but  we  often  find  hy- 
peremia, mucous  exudations,  affections  of  the  nose 
or  throat,  emphysema,  enlargement  of  the  right 
ventricle  and  other  cardiac  lesions,  gout,  rheu- 
matism, syphilis,  nephritis,  and  medullary  lesions 
accompanying  asthmatic  seizures. 

Etiology. — A  peculiar  predisposition  exists,  as 
many  with  similar  lesions  are  not  asthmatic.  This 
malady  is  often  hereditary.  Among  exciting  causes 
may  be  named  bronchitis  (cause  or  effect),  the 
inhalation  of  irritants,  vapors,  dusts,  fogs,  animal 
or  plant  exhalations,  and  all  sorts  of  emotional 
excitement.  Asthma  is  more  common  in  males 
and  the  paroxysms  occur  more  frequently  in  cold 
weather. 

Symptoms. — Prodromes  occurred  in  one-half  of 
Salter's  cases,  such  as  emotional  vagaries,  head- 
ache, neuralgia,  vertigo,  somnolence,  vasomotor 
tension  with  diuresis  and  digestive  disorders. 
Probably  uricemia  may  account  for  many  of  these. 
The  attack  usually  occurs  during  sleep,  tending 
to  recur  at  the  same  hour.    The  symptom  is  dysp- 


42  THE    DISEASES    OF    THE    RESPIRATORY    ORGANS. 

nea,  wheezing  for  breath,  the  patient  feeling  as  if 
the  air  entered  the  lungs  just  so  far  and  then 
stopped.  He  struggles  for  breath,  becomes  pale 
or  cj^anotic,  livid,  with  temperature  subnormal, 
pulse  weak  and  fast,  cold  sweat,  great  depression, 
feels  as  if  about  to  die,  but  never  does  so  in  simple 
asthma. 

The  chest  becomes  rounded,  the  respiration  falls 
to  12,  its  rhythm  is  disturbed,  the  inspiration 
short,  the  expiration  prolonged.  The  diaphragm 
is  lowered  and  expansion  limited.  Palpation  gives 
normal  results  and  percussion  shows  the  chest  to  be 
hyperresonant,  especially  if  emphysema  is  present. 
The  wheezing  expiration  is  audible  at  a  distance, 
with  dry  rales  until  near  the  close  of  the  paroxysm, 
when  serous  rales  are  heard. 

The  paroxysms  last  minutes,  hours,  days  or 
weeks,  with  diurnal  remissions.  They  end  abruptly 
with  expectoration  of  mucinous  molds  of  the  small 
tubes,  known  as  Cushmann's  spirals.  Leyden's 
octahedral  crystals  are  often  present  in  the  sputa, 
and  very  large  numbers  of  eosinophile  leucocytes. 
These  are  also  found  in  excess  in  the  blood  during 
the  attacks.    Later  the  sputa  contains  pus. 

Diagnosis. — The  history  of  previous  attacks, 
absence  of  evidences  of  structural  disease,  abrupt 
cessation  of  the  paroxysms,  inspiratory  dyspnea, 
and  the  presence  of  the  spirals  in  the  sputa,  are 
clearly  diagnostic. 


ASTHMA. 


48 


Prognosis. — Death  rarely  if  ever  occurs  from 
pure  asthma.  'J'he  paroxysms  recur  at  regular 
intervals,  a  group  of  nightly  attacks  beiug  fol- 
lowed by  long  exemption.  Chronic  bronchitis  anrl 
emphysema  are  in  time  developed,  when  the  mal-, 
ady  may  become  practically  continuous.  Com- 
plete recovery  is  also  rare,  unless  the  patient  re- 
moves to  a  suitable  climate. 

Treatment. — The  Paroxysm.  An  emetic  or 
cathartic  may  relieve  by  removing  the  cause  of 
the  attack.  The  most  speedy  relief  ensues  from  a 
counter-irritant  or  ice,  applied  over  the  pneumo- 
gastric  nerve  in  the  neck;  or  from  glonoin  one- 
fourth  milligram  (gr.  1-250),  atropine  one-eighth 
milligram  (gr.  1-500),  and  strychnine  arsenate 
one-half  milligram  (gr.  1-1'M),  given  together 
every  fifteen  minutes  till  relief  ensues.  Very  many 
other  remedies  have  proved  effective  in  relieving 
the  paroxysms,  including  nauseants,  antispasmod- 
ics, stimulants,  anesthetics,  analgesics  and  others, 
many  acting  through  suggestion.  The  use  of 
chloroform,  alcohol,  morphine  and  other  habit- 
drugs,  affords  prompt  relief,  and  as  the  paroxysms 
surely  recur  causes  dangers  infinitely  greater  than 
the  asthma.  They  are  unnecessary  and  should 
never  be  used. 

When  the  paroxysms  are  prolonged,  continuous 
or  quickly  recurrent,  the  patient  should  be  brought 
under  the  full  influence  of  strychnine  arsenate. 


44  THE   DISEASES    OF   THE   RESPIRATORY    ORGANS. 

This  may  require  doses  of  two  milligrams  (gr. 
1-30),  repeated  th'ree  to  ten  times  a  day,  till  the 
full  effect  is  manifest  and  the  malady  controlled; 
and  this  effect  should  be  sustained  until  it  is  found 
that  the  doses  can  be  gradually  lowered  without 
recurrence  of  the  paroxysms.  Maximal  dosage  has 
been  sustained  for  weeks  with  the  best  results.  The 
use  of  this  remedy  in  moderate  doses,  increased 
carefully  but  fearlessly,  offers  the  best  known 
means  of  breaking  up  the  disease  and  effecting 
a  permanent  cure.  Of  course  this  does  not  refer 
to  accompanying  organic  nialadies,  each  of  wliich 
requires  its  own  treatment.  The  bowels,  kidneys, 
diet,  personal  and  domestic  hygiene,  should  also 
be  regulated.  I  am  far  from  advocating  this 
method  of  treating  asthma  to  the  neglect  or  exclu- 
sion of  the  common  duties  of  the  physician,  which 
might  nevertheless  be  allowed  to  go  by  default  if 
not  mentioned. 

When  the  causes  of  the  paroxysms  are  known 
they  must  be  avoided,  for  habit  is  potent  here  as 
elsewhere.  If  any  climate  is  asthmatic  for  an 
individual,  he  may  have  to  choose  between  con- 
tinuing to  be  asthmatic,  and  finding  a  climate 
where  he  will  be  free.  Individual  idiosyncrasy 
rules  here.  The  smoky  air  of  Pittsburg  may  even 
be  better  for  some  persons  than  the  pure  air  of 
Chicago. 

Emphysematous  cases  and  those  accompanied  by 


ASTHMA.  45 


heart-disease  are  greatly  benefited  by  potassium 
iodide  in  full  doses^  tliree  grams  (gr.  xlv)  or  more 
daily. 


CHAPTER  IX. 

PULMONARY  HYPEREMIA. 

Collateral  hyperemia  exists  in  the  unaffected 
lobes  during  pneumonia.  The  bloodvessels  of  the 
lungs  are  acutely  congested,  the  epithelium  swollen 
and  granular.  It  is  the  first  stage  of  pulmonary 
inflammation  and  may  be  excited  by  the  inhala- 
tion of  hot  air^,  irritant  gases,  violent  exercise 
or  emotion,  or  the  excessive  ingestion  of  liquids, 
especially  alcohol. 

There  is  a  sense  of  oppression,  of  a  lack  of  air, 
with  cough,  frothy,  bloody  sputa  and  some  soreness 
in  the  chest.  Examination  shows  both  lungs  usu- 
ally affected,  with  increased  tactile  fremitus,  some 
little  decrease  in  the  clearness  of  the  percussion 
resonance,  diminished  vesicular  respiration,  some 
bronchial  breathing,  and  moist  rales  varying  with 
the  quantity  and  consistence  of  the  fluid  present. 
Eespiration  is  markedly  increased  in  rapidity,  and 
there  is  apt  to  be  some  fever,  the  pulse  correspond- 
ing with  the  fever  present. 

The  diagnosis  is  made  by  the  oppressed  breath- 
ing, cough,  frothy  expectoration  and  the  absence 
of  the  signs  of  pneumonia. 

The  prognosis  is  rendered  grave  by  the  super- 
vention of  pulmonary  edema. 


PULMONARY    HYPEREMIA.  47 

The  treatment  is  very  simple.  The  patient  is 
put  to  bed,  the  bowels  emptied,  free  perspiration 
is  induced  by  the  use  of  pilocarpine,  two  milli- 
grams (gr.  1-30)  every  five  minutes  till  full  action 
is  manifested,  and  the  pulse  is  brought  down  to 
60  by  the  administration  of  veratrine  and  amor- 
phous aconitine,  half  a  milligram  (gr.  1-134) 
each  with  a  milligram  of  digitalin  (gr.  1-67)  to 
contract  the  dilated  pulmonary  vessels,  given  to- 
gether every  quarter  to  one  hour  according  to  the 
urgency  of  the  case.  If  the  patient  is  weakly 
strychnine  arsenate  in  like  doses  should  be  substi- 
tuted for  the  veratrine.  Meanwhile  the  irritating-, 
racking  cough  may  be  checked  by  codeine  and 
emetin,  one  to  three  milligrams  (gr.  1-67  to  1-20) 
each,  every  half  to  one  hour.  If  the  volume  of 
the  blood  is  reduced  by  the  purge  and  sudorific, 
and  the  patient  is  not  permitted  to  restore  the  con- 
gestion by  the  free  use  of  beverages,  it  will  not 
be  necessary  to  bleed,  locally  or  generally.  But  if 
edema  of  the  lung  is  imminent — Ueed—SLEED — 
BLEED  !  Nothing  else  will  act  as  quickly  to  save 
life.  The  fear  our  fathers  felt  in  regard  to  the 
loss  of  a  little  blood  was  preposterous. 

Arterial  tension  may  require  a  few  small  doses 
of  glonoin  at  first,  to  let  in  the  veratrine  more 
speedily,  and  let  out  the  blood  from  the  hyperemic 
area. 


CHAPTER  X. 
PULMONARY  EDEMA. 

In  many  morbid  conditions  blood-serum  is  ef- 
fused into  the  air-cells  and  pulmonary  tissues.  It 
forms  a  zone  around  pneumonic,  purulent  apoplec- 
tic and  tubercular  masses.  It  is  an  incident  in  the 
history  of  nephritis,  anemia,  apoplexy,  acute  septic 
fevers  and  many  cardiac  maladies.  In  pneumonia 
collateral  hyperemia  and  edema  of  the  lobes  not 
pneumonic  form  a  serious  element  of  danger.  In 
true  croup  edema  is  the  cause  of  death.  The  oc- 
currence of  edema  is  favored  by  any  agent  that 
causes  abnormal  fluidity  of  the  blood,  overfilling 
of  the  pulmonary  capillaries,  increase  or  decrease 
of  the  tension  of  the  pulmonary  bloodvessels,  or 
innutrition  of  their  walls. 

Dyspnea  is  the  first  symptom,  and  is  severe  in 
proportion  to  the  extent  of  the  malady.  Cough, 
frothy  sero-sanguineous  expectoration,  cyanosis 
with  sluggishness,  somnolence  and  finally  death  by 
carbonic  acid  poisoning,  are  the  steps  in  general 
pulmonary  edema.  The  pulse  is  weak  and  rapid, 
skin  cool  and  livid,  the  degree  of  fever  depends  on 
the  causal  malady.  The  percussion  note  is  dull 
if  the  edema  is  marked;  auscultation  discloses 
moist  rales  of  varying  degree,  beginning  in  the 


PULMONARY    EDEMA.  49 

finest  bronchi  and  becoming  coarser  as  the  senim 
invades  larger  ones,  while  the  vesicular  sound  is 
weak  or  absent. 

The  condition  is  diagnosed  from  the  history, 
incomplete  dullness  beginning  in  dependent  parts, 
the  progressively  larger  moist  rales,  frothy  bloody 
sputa,  absence  of  fever  and  supervention  of  cyano- 
sis if  extensive.  In  hydrothorax  the  level  of  the 
dullness  changes  at  once  with  change  of  posture, 
and  there  are  no  rales.  Broncho-penumonia  begins 
with  fever,  sticky  gray  sputa,  and  the  dullness  is 
marked,  limited  and  stationary. 

The  prognosis  depends  on  the  primary  disease. 
Collateral  edema  is  a  condition  of  imminent  dan- 
ger.   In  croup  it  is  a  herald  of  death. 

Treatment. — Treat  the  primary  malady. 
Change  the  patient's  posture  frequently  to  avoid 
hypostasis.  Bleed  for  collateral  edema  in  pneumo- 
nia. Intubate  to  prevent  edema  in  croup.  Feed 
up,  stimulate,  and  neglect  not  the  blood-pressure. 


CHAPTER  XI. 

HEMOPTYSIS. 

Blood  coughed  up  comes  usually  from  the 
bronchi;  rarely  in  advanced  phthisis  it  is  from 
eroded  vessels.  At  the  post-mortem  we  find  the 
latter,  or  ruptured  capillaries,  swollen  mucosa,  or 
a  ruptured  aneurism  the  affected  lung-tissue  pale. 

Etiology. — The  causes  may  be  pulmonary 
hyperemia  or  congestion  from  any  cause  (heart- 
disease,  pneumonia,  inhalation  of  hot  air,  violent 
exercise,  etc.),  infarction,  pneumonia,  tubercle, 
ulcer  of  larynx,  trachea  or  bronchi,  fibrinous  bron- 
chitis, cancer  and  gangrene.  Blood  may  come 
from  the  nose  or  from  other  sources,  enter  the 
larynx  during  sleep  and  be  coughed  up  to  frighten 
the  patient  and  mislead  the  doctor. 

A  free  hemorrhage  may  first  attract  attention 
to  a  localized  deposit  of  miliary  tubercle.  Much 
more  frequently  children  who  bleed  at  the  nose 
during  early  life,  after  reaching  puberty  have  bronr- 
chial  hemorrhages  instead.  The  effused  bloo^,  de- 
composing in  the  bronchi,  excites  inflammation 
there,  and  this  may  form  a  suitable  nidus  for  the 
tubercle  bacillus.  Too  many  young  people  have 
repeated  bronchial  hemorrhages,  and  yet  live  to 
old  age  without  becoming  phthisical,  to  permit  of 


HEMOPTYSIS.  51 

the  gloomy  prognosis  of  Laennec  in  similar  cases. 

Rarely  hemoptysis  represents  a  vicarious  men- 
struation. Purpura  hemorrhagica,  scurvy,  ptyal- 
ism,  anemia,  hemophilia  yellow  fever  and 
malignant  malarial  fever,  may  cause  hemoptysis. 
Clarke  found  recurrent  hemorrhages  in  aged  per- 
sons from  gouty  endarteritis. 

Symptoms. — In  bronchial  hemorrhages  the  pa- 
tient feels  a  warm  salty  taste  and  blood  wells  up 
into  his  mouth,  the  quantity  varying  from  an 
ounce  to  a  pint.  This  is  generally  preceded,  per- 
haps for  days,  by  a  sense  of  stuffiness  in  the  chest, 
with  pain  or  tenderness  in  the  second  right  inter- 
costal space,  near  the  sternum.  The  patient  is 
frightened,  the  pulse  excited,  full  and  rapid,  per- 
haps tumultuous.  Each  new  gulp  of  blood  adds 
to  the  terror.  During  the  day  a  second  hemorrhage 
usually  occurs,  and  if  this  is  foretold  by  the  doctor, 
with  the  assurance  of  its  harmlessness,  faith  and 
composure  follow.  Otherwise  another  attendant 
is  usually  summoned.  Blood  is  brought  up  for  a 
few  days,  while  the  patient  shows  by  fever  the  de- 
gree of  damage  excited  by  the  dead  blood  in  the 
fragile  lung-tissues.  If  oppression  has  preceded,  a 
feeling  of  relief  and  sense  of  well-being  follows 
the  hemorrhage.  Earely  is  the  loss  of  blood  suffi- 
cient to  induce  syncope  and  collapse.  The  assump- 
tion of  latent  tubercular  foci  is  totally  unnecessary 


52  THE  DISEASES    OF   THE   RESPIRATORY   ORGANS. 

here,  and  contrary  to  the  observations  I  have  made 
of  the  future  history  of  many  such  cases. 

When  tuberculosis  is  advancing  rapidly  a  large 
vessel  may  be  eroded,  in  which  case  the  succeeding 
hemorrhage  is  apt  to  be  fatal.  The  blood  in  the 
above  cases  iis  arterial  and  frothy,  not  clotted. 
Bubbling  rales  may  be  heard  on  auscultation. 

Similar  hemorrhages  may  occur  in  passive  con- 
gestions from  obstructive  heart-disease,  etc.,  and 
spitting  of  blood  or  bloody  sputa  is  common  in 
any  destructive  pulmonary  affection. 

Small  hemoptyses  precede  for  weeks  the  rupture 
of  thoracic  aneurism,  the  latter  causing  sudden 
death. 

Gouty  hemoptysis  occurs  after  50,  most  com- 
monly when  bronchitis  is  present.  Small  hemor- 
rhages occur  in  emphysema  also,  probably  from 
ulcer. 

Small  hemoptyses  occur  in  weak,  hysterical 
women,  others  follow  thoracic  injuries,  strains  and 
violent  emotions.  Persons  predisposed  to  tubercu- 
losis are  apt  to  have  hemorrhages  if  they  go  to  the 
seashore,  and  almost  any  one  may  suffer  similarly 
on  ascending  to  elevated  regions  or  in  balloons. 

The  diagnosis  of  pulmonary  hemorrhage  is  made 
by  ascertaining  that  the  blood    is  coughed  up, 
frothy,  bright-red,  the  nose,  mouth    and  throat 
showing  no  source  of  bleeding,  the  lung  reveal- 
ing it. 


HEMOPTYSIS.  58 

The  prognosis  is  good  as  to  life.  Very  rarely 
does  any  one  die  from  pulmonary  hemorrhage, 
except  from  erosion  of  an  artery  or  bursting  of 
an  aneurism.  But  any  discharge  of  blood  from 
the  lung  demands  the  most  thorough  search  for 
evidence  of  tuberculosis.  If  not  found,  if  the 
week  following  shows  little  fever  and  the  sputa 
are  free  from  pathogenic  microbes,  the  hemorrhage 
is  still  evidence  of  a  fragility  of  tissue  demanding 
instant  attention.  The  immediate  effect  of  a  hem- 
orrhage on  the  course  of  an  acknowledged  tuber- 
cular malady  is  beneficial.  Simple  blood-spitting 
is  rather  diagnostic  than  prognostic. 

Treatment. — Place  the  patient  at  ease,  the  head 
somewhat  elevated,  with  cold  to  the  chest.  Eeas- 
sure  him  as  to  immediate  danger,  announce  the 
return  of  another  hemorrhage  later  in  the  day, 
administer  a  full  dose  of  atropine,  a  milligram 
(gr.  1-67),  turn  the  people  out  of  the  room  and 
order  the  patient  to  be  kept  cool  and  quiet.  For- 
bid the  patient's  talking.  If  the  sense  of  oppression 
is  still  present,  apply  a  leech  or  cup  over  the  second 
right  intercostal  space,  close  to  the  sternum,  and 
subdue  the  bounding  heart  with  aconitine  or  vera- 
trine,  "dose  enough"  to  do  the  work.  Keep  the 
patient  very  quiet  as  long  as  any  fever  is  present, 
feeding  on  smaU  doses  of  ice-cream  and  the  most 
concentrated  nutriment,  predigested  if  necessary. 
Forbid  all  fluid  but  what  is  absolutely  unavoidable. 


54  THE   DISEASES    OF   THE    RESPIRATORY    ORGANS. 

For  thirst  allow  pellets  of  ice,  or  chewing-gum. 
Examine  the  chest  thoroughly.  If  a  tubercular 
lesion  is  found  treat  that  disease.  Heart-disease, 
aneurism,  etc.,  require  their  own  treatment.  In 
case  of  aneurism  ice  to  the  chest  may  delay  death 
for  a  paltry  period.  In  vicarious  menstruation 
anticipate  the  next  monthly  epoch  by  active 
emmenagogues,  and  repeat  this  each  month  till 
it  is  no  longer  necessary. 

If  the  most  vigorous  search  fails  to  disclose  evi- 
dence of  pulmonary  tuberculosis,  while  the  history 
and  aspect  of  the  patient  show  the  case  to  be  one 
of  tissue-fragility,  predisposition  to  phthisis,  the 
question  is  of  prophylaxis.  If  a  youth  of  proper 
age,  a  long  sea-voyage,  a  year  or  more,  is  advisable. 
Calcium  lactophosphate  should  be  given,  half  a 
gram  (gr.  7-J)  daily  for  a  year  or  more;  the  bow- 
els regulated,  the  digestion  scientifically  built  up, 
the  body  invigorated  and  toughened  by  suitable 
exercise,  cold  baths,  salt  rubs,  pneumonic  gymnas- 
tics, cod-liver  oil  inunctions,  the  climate  suitable 
to  the  case,  etc. 

Whenever  there  is  the  warning  sense  of  oppres- 
sion the  heart  should  be  sedated  by  veratrine  and 
a  dry  cup  placed  over  the  danger-point.  If  the 
symptoms  recur  quickly,  introduce  a  seton  wher- 
ever pain  or  fullness  is  felt. 

The  diet  must  be  carefully  suited  to  the  case. 
A  flood  of  hot  soup  or  alcoholic  beverages  may 


HEMOPTYSIS. 


56 


bring  on  hemorrhage.  All  excesses  that  impair 
the  vitality  must  be  prevented.  An  out-door  life, 
in  an  equable  climate,  as  high  up  the  mountains 
as  the  patient  can  comfortably  endure,  is  the  ideal. 
While  emphatic  in  my  view  that  these  cases  are 
not  necessarily  tuberculous,  I  grant  freely  their 
liability  to  become  so,  and  the  regime  enjoined  is 
that  employed  to  prevent  the  development  of  tuber- 
culosis. This  point  is  of  the  utmost  importance, 
for  many  a  doctor  and  patient,  convinced  by  the 
hemorrhage  of  the  preexistence  of  tuberculosis, 
have  allowed  the  cases  to  go  by  default  that  might 
otherwise  have  lived  to  a  healthy  old  age. 

I  have  dropped  all  the  old  hemostatics  for  atro- 
pine. By  forcibly  dilating  the  cutaneous  capil- 
laries this  drug  attracts  the  blood  to  the  surface 
and  reduces  the  congestion  of  the  internal  organs. 
If  the  blood  is  safely  held  at  the  periphery  it  can- 
not at  the  same  time  be  escaping  from  engorged 
vessels  in  the  lungs.  Besides  this,  atropine  sedates 
the  pneumogastric  and  checks  the  cough.  While 
it  is  in  a  sense  antagonistic  to  the  arterial  sedatives 
recommended,  aconitine  and  veratrine,  actual  trial 
has  confirmed  the  apparently  paradoxic  claim  that 
such  antagonists  will  act  in  the  same  body  at  the 
same  time,  each  exerting  its  special  force  where 
needed.  It  is  well  to  accompany  the  atropine  with 
a  few  doses  of  glonoin,  J  milligram  (gr.  1-350) 
every  ten  minutes,  to  relax  arterial  tension,  open 


56  THE   blSEASES   OF  TtlE  RiESPIRATORY  ORGANS. 

the  vessels  for  speedier  action  of  the  other  drugs, 
combat  the  tendency  to  syncope  and  attract  the 
blood  to  the  head,  where  it  is  held  by  the  slower 
but  more  persistent  atropine.  The  only  effect  of 
astringent  sprays  is  upon  the  mentality  of  the 
patient,  for  by  no  possibility  can  they  reach  the 
bleeding  orifices. 


CHAPTER  XII. 
PULMONARY  APOPLEXY. 

Sometimes  there  is  an  escape  of  blood  into  the 
lung-tissues,  similar  to  a  cerebral  apoplexy.  It 
occurs  from  rupture  of  an  adherent  aneurism,  from 
wounds,  and  in  some  cerebral  and  septic  maladies. 

There  is  profuse  hemoptysis,  great  dyspnea, 
cyanosis,  collapse  and  signs  of  consolidation  sud- 
denly following  the  causal  lesion.  It  ends  in  death 
at  once,  or  after  abscess  or  gangrene  has  super- 
vened. 

The  treatment  is  absolute  rest,  cold  locally,  and 
atropine  in  full  doses  hypodermically,  one  milli- 
gram (gr.  1-67)  at  once. 


CHAPTER  XIII. 
PULMONARY  EMBOLISM. 

A  pulmonary  artery  is  blocked  by  an  embolus. 
The  lung  supplied  becomes  engorged  with  blood, 
airless,  dark,  the  pleura  covering  the  base  of  the 
wedge  inflamed,  and  a  zone  of  edema  surrounds  it. 
If  the  embolus  consisted  of  septic  matter  the  part 
breaks  down  into  an  abscess.  In  leucocythemia 
plugs  composed  of  leucocytic  masses  form  small 
emboli.  Vegetations  loosening  from  the  valves  of 
the  heart  sometimes  enter  the  lungs. 

Small  non-septic  emboli  may  occasion  no  sjnnp- 
toms;  large  ones  may  cause  speedy  death  with 
symptoms  of  pulmonary  apoplexy.  The  usual 
symptoms  are  dyspnea,  syncope,  pleuritic  pain, 
spasms  and  coma.  The  dyspnea  occasions  great 
distress  and  struggling  for  breath.  Bloody  ex- 
pectoration occurs  early.  If  a  cardiac  murmur 
ceases,  with  the  sudden  development  of  local- 
ized pneumonia,  hemoptysis,  pleuritic  pains, 
preceded  by  convulsions  and  unconscious- 
ness, the  diagnosis  is  clear.  Small  infarctions  may 
not  cause  dullness ;  large  ones  do,  with  moist  rales, 
increased  fremitus  and  bronchial  respiration,  with 
pleuritic  friction.    The  pulse  is  weak  and  rapid, 


PULMONARY    EMBOLISM.  59 

skin  cool,  the  forces  prostrated.  Fever  follows 
reaction  in  large  infarctions. 

The  prognosis  depends  on  the  nature  of  the 
embolus  and  the  importance  of  the  vessel  occluded. 
If  abscess  or  gangrene  occur  death  quickly  fol- 
lows. In  case  of  recovery  the  affected  part  shrinks, 
forming  scar-tissue,  or  calcifies. 

The  treatment  consists  of  rest,  careful  feeding 
to  support  the  strength,  and  anodynes  to  ease  the 
pain.  Atropine  may  be  given  for  this  purpose, 
with  codeine  enough  to  prevent  painful  cough,  and 
anodyne  applications  to  the  skin. 


CHAPTER  XIV. 

BRONCHO-PNEUMONIA 

In  capillary  bronchitis  we  find  evidences  of  in- 
flammation of  the  smallest  bronchi  and  the  air- 
cells.  Dark  patches  are  found,  surrounded  by 
healthy  tissue,  the  one  exuding  muco-pus  when  cut, 
the  other  serum.  The  large  bronchi  are  healthy, 
the  smaller  contain  secretions,  the  walls  thick,  di- 
lated, the  cut  surfaces  nodular.  Large  areas  may 
be  almost  wholly  consolidated,  airless,  at  first  red- 
dish, later  gray.  Both  lungs  are  affected  in  parts. 
The  bronchial  glands  are  inflamed,  the  pleura 
somewhat  also,  the  air-cells  of  other  parts  of  the 
lungs  dilated.  The  malady  begins  as  an  inflam- 
mation of  the  cells  and  bronchioles  constituting  a 
lobule,  new  tissue  being  formed  therein,  the 
malady  tending  to  chromicity.  The  exudate  con- 
sists of  serum,  mucus,  alveolar  cells,  leucocytes, 
and  a  few  red  blood-cells.  The  leucoc3rtes  in  the 
blood  multiply,  except  in  fatal  cases.  Concomitants 
are  bronchial  catarrh  and  exudative  inflammation 
of  the  air-cells. 

Etiology. — The  malady  is  most  frequent  among 
children,  and  with  measles,  rickets,  scarlatina, 
whooping-cough  and  diphtheria.  Excitants  are 
exposure  to  cold  and  wet,  bad  air,  bad  hygiene 


BRONCHO-PNEUMONIA.  61 

and  digestive  derangements.  A  form  of  broncho- 
pneumonia also  prevails  among  the  aged,  enfeebled 
by  disease.  It  is  most  prevalent  in  cold,  wet  sea- 
sons, occurs  with  influenza,  typhoid  fever,  erysipe- 
las and  smallpox.  The  inhalation  of  irritants 
seems  to  excite  attacks,  as  does  the  tubercle  bac- 
illus. 

Streptococci  are  frequently  found  in  the  sputa, 
also  pneumococci,  staphylococci  aurei,  the  influ- 
enza bacilli  and  numerous  other  micro-organisms. 

Symptoms. — Primary  forms,  occurring  usually 
in  adults,  present  symptoms  of  severe  acute  bron- 
chitis. In  weak  patients  the  onset  may  be  gradual. 
The  eputa  is  scanty  and  sticky,  gray  or  blood 
stained,  fever  101°  to  104°  F. ;  irregular  but  high- 
er in  evenings,  ending  by  lysis  in  two  to  four 
weeks. 

More  common  is  the  secondary  form,  the  early 
symptoms  masked  by  the  previous  aflection.  The 
malady  extends  down  from  the  larger  bronchi  and 
is  marked  by  a  sudden  rapidity  of  respiration, 
with  higher  fever,  harassing  cough  and  expectora- 
tion.   The  pulse  grows  rapid,  feeble  and  irregular. 

Capillary  bronchitis  is  indicated  by  subcrepitant 
rales,  followed  by  some  dullness,  not  limited  to 
single  lobes,  but  more  marked  in  the  back  between 
the  shoulder-blades.  Dyspnea  and  duskiness  of  the 
lips  are  noted,  the  hurry  of  respiration  is  extreme, 
the  eyes  and  finger-nails  are  blue.    The  respirations 


62  THE  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

are  shallow.  The  fremitus  is  increased,  breathing 
is  bronchial,  yet  the  consolidation  is  rarely  as  com- 
plete as  in  lobar  pneumonia. 

Unless  death  comes  sooner  the  attacks  last  from 
one  to  several  weeks. 

In  the  cerebral  form  there  are  at  the  outset  rest- 
lessness, convulsions  and  delirium  or  stupor,  early 
high  fever,  followed  by  prostration.  Some  days 
later  the  pulmonary  symptoms  replace  the  cerebral. 
There  may  be  gastro-intestinal  disorders  in  any 
form.  Some  cases  run  on  for  many  weeks,  the 
consolidation  remaining.  In  fact,  the  affected 
areas  may  remain  permanently  solidified.  The 
fever  may  be  irregular.  Other  cases  develop  like 
lobar  pneumonia,  with  chills,  high  fever,  pain  in 
head,  chest  and  back,  marked  prostration  follow- 
ing, with  the  usual  symptoms  in  aggravated  form. 
In  another  group  the  onset  is  insidious,  the  course 
chronic,  hectic  fever  and  night-sweats  following. 

The  diagnosis  between  this  affection  and  lobar 
pneumonia  is  not  as  a  rule  difficult.  Lobar  pneu- 
monia begins  abruptly  with  a  chill,  there  is  crepi- 
tation, followed  by  dullness  limited  to  one  or  more 
lobes,  rusty  sputa,  typical  fever,  ending  in  crisis; 
it  is  often  unilateral,  without  bronchial  catarrh 
or  severe  dyspnea;  the  pneumococcus  is  present. 
Broncho-pneumonia  develops  usually  out  of  one  of 
the  maladies  named ;  begins  gradually  with  bron- 
chitis preceding ;  the  dullness  is  bilaterial,  not  ab- 


BRONCHO-PNEUMONIA.  63 

solute,  not  limited  to  the  lobes,  but  most  marked 
between  the  scapulae;  subcrepitant  rales,  respira- 
tion hurried,  great  dyspnea  and  cyanosis,  fever 
irregular,  ending  by  lysis,  course  prolonged,  sputa 
glairy,  in  adults  blood-spotted;  often  ends  in  tu- 
berculosis ;  streptococci  and  other  micro-organisms 
than  pneumococcus  are  present. 

Pleurisy  has  dullness  at  the  base  of  one  or  both 
lungs.    In  tuberculosis  the  bacillus  is  present. 

The  prognosis  is  grave  in  proportion  to  the  weak- 
ness of  the  patient  and  the  extent  of  the  disease. 
The  mortality  varies  from  25  to  50  per  cent. 

Treatment. — Attacks  may  be  prevented  by 
guarding  against  colds  during  and  after  the  affec- 
tions above  named.  The  mouth  should  be  regularly 
cleansed  with  antiseptic  lotions  during  all  septic 
fevers. 

Perhaps  no  other  remedy  counts  for  so  much  in 
this  malady  as  the  constant  inhalation  of  steam. 
The  chest  should  be  painted  with  tincture  of  iodine 
and  enveloped  in  a  mush- jacket,  covered  thickly 
with  dry  flannels.  The  more  acute  cases  require 
veratrine,  aconitine  and  digitalin  for  the  fever, 
changing  the  veratrine  to  strychnine  arsenate  at 
the  first  indication  of  debility.  The  adult  dose  is 
half  a  milligram  of  each,  except  of  digitalin,  which 
is  a  milligram  every  half,  one  or  two  hours,  ac- 
cording to  the  pulse  and  the  fever.  For  children 
under  ten  Shaller's  rule  is  applicable:    Put  in  a 


64  THE  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

glass  one  adult  dose  for  each  year  of  the  child^s 
age,  add  one  more,  and  24  teaspoonfuls  of  water; 
then  give  a  teaspoonful  as  often  as  required.  Thus, 
a  child  one  year  old  would  take  two-twenty-fourths 
of  the  adult  dose,  a  child  8  years  old  nine-twenty- 
fourths. 

The  bowels  must  be  emptied  and  kept  soluble, 
the  strength  supported  by  judicious  feeding,  the 
alimentary  canal  aseptic. 

Will  any  agent  favor  resolution  and  fluidify  the 
exudate?  I  am  uncertain.  Calomel,  ipecac,  am- 
monium chloride,  apomorphine,  lobelia,  potassium 
bichromate,  each  has  been  faithfully  tried  without 
giving  convincing  proof  of  its  utility.  One  case 
responded  promptly  to  ammonium  iodide,  another 
to  strychnine  in  desperate  doses;  and  I  would 
to-day  prefer  the  latter  to  any  other  remedy. 
Opiates  in  all  forms  are  deadly.  The  cough  will 
be  better  relieved  by  steam.  The  inhalation  of 
oxygen  may  tide  over  a  case.  Injections  of  normal 
salt  solution  may  be  of  value. 


CHAPTER  XV. 

PULMONARY  GANGRENE. 

Diffuse  gangrene  in  the  lungs  is  rarely  met  in 
pneumonia.  As  a  consequence  of  occlusion  of 
a  large  artery  a  whole  lobe  or  lung  may  be 
affected,  the  tissues  becoming  black,  soft  and 
putrid.  Emboli  cause  circumscribed  gangrene, 
more  frequent  in  the  right  lung,  and  in  the  lower 
lobes  close  to  the  pleura.  The  tissues  turn  greenish 
brown,  softening  at  the  center  into  a  cavity.  A 
zone  of  inflamed  tissue  surrounds  it  and  the  dis- 
charge inflames  the  air-passages  it  reaches.  The 
affection  spreads  by  direct  extension  to  lung  and 
pleura,  and  secondary  embolism  may  occur  in  the 
brain  or  elsewhere.  The  gangrenous  patch  may 
become  encysted  and  the  patient  recover  with  a 
cavity.  * 

The  causes  are  putrefactive  bacteria,  staphy- 
lococci, lodging  on  pulmonary  tissues  whose  vital- 
ity has  been  reduced  too  low  for  successful 
resistance.  Gangrene  occurs  in  the  course  of 
pneumonia,  infarctions,  bronchiectatic  and  other 
cavities,  traumatisms,  cancer,  compression  and 
embolism.  Foreign  bodies,  food,  etc.,  entering  the 
lung  are  specially  liable  to  cause  gangrene.  It 
occurs  sometimes  in  convalescents  and  in  diabetics. 


66  THE  DISEASES   OF  THE  RESPIRATORY   ORGANS. 

The  symptoms  are  cough,  profuse  intensely 
fetid  sputa,  separable  on  standing  into  three  layers, 
an  upper-frothy,  gray-yellow,  a  middle  clear 
serous,  a  lower  greenish-brown  sediment  contain- 
ing shreds  of  lung-tissue,  blood,  bacteria,  fat- 
crystals,  muco-pus,  amorphous  matter  and  lepto- 
fehrix.  Ciliated  monads  have  been  found.  If  the 
gangrene  does  not  discharge  by  the  bronchi,  neither 
fetor  nor  sputa  may  be  present.  Fatal  hemorrhage 
may  result  from  erosion  of  an  artery.  The  physi- 
cal signs  are  those  of  consolidation,  with  a  cavity 
after  evacuation ;  the  usual  rales  from  the  bronchi 
and  inflamed  layer.  There  is  fever  of  irregular 
type,  with  great  prostration  and  rapid  wasting, 
death  advancing  rapidly. 

The  diagnosis  is  made  by  the  unequalled  fetor 
of  the  breath,  peculiar  sputa  and  rapid  sinking. 

The  prognosis  is  grave  in  proportion  to  the  ex- 
tent and  rapidity  of  the  gangrenous  process. 

Treatment. — Spray  or  atomize  with  carbolic 
lotions  and  volatile  oils,  as  strong  as  can  be  borne. 
Give  the  latter  internally  in  full  doses,  with  san- 
guinarine,  strychnine  and  the  richest  possible 
diet.  Just  as  soon  as  there  is  an  opening  for 
surgical  intervention  it  should  be  embraced. 


CHAPTER  XVI. 
PULMONARY  ABSCESS. 

Abscess  of  the  lung  may  be  diffuse  or  circum- 
scribed, of  any  size  up  to  an  entire  lobe.  If  the 
pleura  is  reached  there  may  be  fibrinous  adhesions, 
emphysema,  or  pyopneumothorax.  Streptococci, 
pneumococci,  Friedlsender's  bacilli  and  other 
organisms  have  been  found.  Abscess  has  been 
found  to  follow  pulmonary  inflammations  (usually 
diffuse,  perforations,  embolisms,  pyemia,  emphy- 
sema, and  usually  attends  chronic  tuberculosis. 

The  sputa  contain  pus,  are  fetid,  but  less  than 
in  gangrene,  containing  many  elastic  fibers.  The 
cavity  can  be  located  if  large  enough.  The  fever 
is  of  the  hectic  type,  with  chills,  perhaps  daily. 

Pyemic  abscess  presents  little  hope.  If  the 
causal  affection  is  amenable  to  treatment  the 
abscess  is  a  harmful  event,  not  necessarily  fatal. 

Treatment. — Keep  up  the  patient's  strength 
with  rich  food,  strychnine  arsenate  two  milligrams 
(gr.  1-30),  iron  and  quinine  arsenates  each  a  cen- 
tigram (gr.  1-6)  every  four,  three  or  two  hours; 
with  all  the  resources  of  the  reconstructive  regime. 
Put  a  stop  to  the  suppurative  process  by  speedily 
saturating  the  body  with  calcium  sulphide,  one 
grain,  seven  times  or  more  each  day  till  the  breath 


68  THE  DISEASES  OF  THE  RESPIRATORY   ORGANS. 

smells  of  the  drug.  Spray  with  volatile  oils, 
thymol,  menthol,  eucalyptol  and  camphor,  one 
gram  (gr.  xv)  each  in  an  ounce  of  fluid  petro- 
latum, very  often.  Aspirate  or  drain  large  ab- 
scesses as  early  as  practicable. 


CHAPTER  XVII. 
PLEURISY. 

All  inflammations  of  the  pleura  are  attributable 
to  micro-organisms.  In  the  exudate  have  been 
found  tubercle  and  typhoid  bacilli,  strepto- 
staphylo-  and  pneumococci.  In  emphysema  the 
ordinary  forms  are  micrococcus  lanceolatus  and 
streptococcus.  Less  common  are  the  colon  bacillus, 
proteus  vulgaris,  gonococcus  and  Friedl^nder's 
bacillus,  with  several  saprophytic  bacteria.  In  half 
the  cases  more  than  one  form  is  present. 

DRY  PLEURISY. 

In  acute  plastic  pleurisy  the  inflamed  surface 
is  injected,  dull,  with  bloody  points,  covered  with 
a  fibrinous  exudate,  which  thickens  from  friction, 
becoming  shaggy,  yellowish  or  reddish-gray.  Em- 
bryonic cells  in  the  exudate  develop  new  vessels 
and  connective  tissue.  The  opposing  surfaces  ad- 
here in  severe  forms ;  in  lighter  cases  the  exudate 
becomes  fatty  and  is  absorbed. 

This  form  of  pleurisy  rarely  occurs  primarily, 
from  cold,  or  with  a  diathesis  present.  Second- 
arily it  occurs  with  pneumonia  and  other  pulmon- 
ary inflammations,  and  tuberculosis,  when  they 
extend  to  the  pleural  limit  of  the  lung.    In  rheu- 


70  THE  DISEASES  OF  THE  RESPIRATORY    ORGANS. 

matism,  nephritis  and  alcoholism  it  is  common, 
and  it  may  also  follow  other  serous  inflammations. 

The  symptoms  are  of  all  degrees  of  severity. 
The  pleuritic  stich  in  the  side  is  noted.  The  pain 
is  increased  by  chest-movement,  hence  breathing 
is  restrained  and  cough  suppressed.  When  the 
opposing  surfaces  have  become  glued  together  this 
is  relieved.  The  fever  ranges  from  101°  to  103°  F. 
— often  it  is  hardly  noticeable;  the  pulse  90  to 
100,  small  and  soft.  In  many  cases  the  disease  is 
"latent,"  and  the  patient  really  never  knows  he  is 
affected;  while  in  some  there  is  the  evidence  of  a 
serious  malady,  fever  of  104°  F.,  chills,  pros- 
tration, and  other  symptoms  of  corresponding 
gravity. 

The  chest-movements  are  restricted,  percussion 
note  unaltered,  but  a  friction  sound  is  heard  in  the 
early  stages — ^the  "dry-leather"  rubbing,  heard 
most  clearly  at  the  end  of  the  inspiration.  When 
exudation  occurs  fremitus  is  said  to  be  diminished 
and  some  dullness  to  be  detectable,  but  it  must 
be  quite  unusual  for  enough  exudation  to  appear 
to  render  this  possible.  Friction  is  then  heard  on 
expiration  and  inspiration.  If  the  exudation  is 
abundant  enough  to  compress  the  lung  there  may 
be  bronchial  breathing,  and  it  may  require  a  deli- 
cate diagnosis  to  determine  if  this  is  the  case  or 
the  adjacent  lung  is  pneumonic. 
The  diagnosis  is  made  by  the  friction-sound. 


PLEURISY.  71 

stitch,  suppressed  dry  cough  and  respiration,  with 
the  absence  of  evidences  of  pneumonia — crepitus, 
rusty  sputa  and  dullness.  Intercostal  neuralgia 
has  tender  spots,  but  no  friction  sounds  or  fever. 

The  attacks  run  on  from  a  few  days  up  to  some 
weeks,  and  end  in  resolution  with  absorption,  per- 
manent adhesion  of  the  opposing  pleural  surfaces, 
or  death.  A  predisposition  to  subsequent  attacks 
remains. 

Treatment. — Put  the  patient  to  bed ;  limit  the 
pain  and  spread  of  inflammation  by  applying  as 
tightly  as  possible  a  bandage  or  corset  to  the  chest, 
as  in  fracture  of  the  ribs ;  relieve  the  pain  if  severe 
by  leeching  or  cupping  over  the  painful  region 
and  reduce  the  hyperemia  to  the  lowest  point  by 
rapidly  reducing  the  bulk  of  the  blood.  Our 
fathers  did  this  by  bleeding,  and  in  many  cases 
this  is  a  wise  procedure  to-day,  but  not  in 
diathetic  or  cachectic  cases,  or  in  individuals  whose 
vitality  is  deficient.  Better  enjoin  the  dry  diet, 
total  abstinence  from  drink  and  bulky  or  watery 
food  give  a  brisk,  quick-acting  cathartic,  and 
enough  pilocarpine  to  induce  free  sweating  (two 
milligrams  (gr.  1-30),  every  ten  minutes  till  full 
effect) .  With  this,  relax  the  contracted  capillaries 
(vaso-motor  spasm)  by  aconitine  amorphous,  half 
a  milligram  (gr.  1-134),  restore  contractility  to  the 
vessels  in  the  hyperemic  area  (vasomotor  paresis) 
by   strychnine   arsenate   half   a   milligram    (gr. 


72  THE  DISEASES   OF  THE  RESPIRATORY   ORGANS. 

1-134),  and  digitalin  a  milligram  (gr.  1-67),  and 
if  needed  subdue  excessive  heart-action  and 
arterial  tension  by  veratrine  half  a  milligram  (gr. 
1-134),  given  together  every  quarter,  half,  one  or 
two  hours,  as  indicated  by  the  severity  of  the 
symptoms,  till  the  desired  effect  is  manifested. 
Here  again  we  have  an  illustration  of  the  singular 
fact  that  antagonistic  remedies  may  be  given  to- 
gether and  each  be  appropriated  by  the  tissues  re- 
quiring its  aid  to  restore  physiologic  equilibrium. 
During  convalescence  respiratory  gymnastics 
should  be  employed,  to  restore  the  expansion  of  the 
lung  and  prevent  adhesions.  A  full,  long  breath 
or  two,  taken  every  two  hours,  is  a  useful  measure. 
Iodine  and  mercury,  the  great  absorbents,  should 
be  applied  locally  and  taken  internally.  The 
official  compound  iodine  ointment,  with  a  scruple 
of  mercury  biniodide  to  the  ounce,  may  be  rubbed 
into  the  skin  twice  a  day.  Internally  iodoform, 
hydriodic  acid,  the  iodides  of  iron,  mercury,  calci- 
um or  arsenic,  may  be  given  as  indicated,  alone  or 
combined,  the  object  being  to  get  the  greatest  pos- 
sible effect  while  the  exudate  is  still  young  and 
amenable  to  reason.  I  usually  cover  the  skin  over 
the  affected  region  with  belladonna  plaster  con- 
taining camphor,  and  have  this  worn  for  a  month 
or  more  on  dismissing  the  case.  Bearing  in  mind 
the  frequency  of  tuberculosis  as  a  cause  or 
sequence  of  this  malady,  I  rarely  allow  a  patient 


PLEURISY.  73 

to  be  beyond  observation  for  a  year  after  such  an 
attack,  and  employ  the  measures  usual  for  persons 
prone  to  that  malady — diet,  personal  hygiene,  oc- 
cupation, climate,  etc. 

SEROUS  PLEUKISY. 

While  in  the  affection  last  treated  a  portion  only 
of  one  pleura  is  affected,  in  the  effusive  form  the 
whole  of  one  sac  participates  in  the  inflammation. 
The  malady  is  by  that  much  the  more  grave.  The 
pathological  changes  are  similar,  save  that  the 
exudation  is  more  copious  and  serous,  with  a 
fibrinous  layer  of  varying  thickness  on  the  surface 
of  the  affected  membrane.  The  fluid  contains 
varying  amounts  of  fibrin,  and  may  be  but  a  few 
ounces,  or  several  quarts,  in  bulk.  It  is  clear  or 
turbid,  water-white,  yellowish  to  brown.  At  first 
it  settles  in  the  most  dependent  parts,  and  if  the 
whole  sac  is  not  filled,  inflammatory  adhesion  takes 
place,  confining  the  fluid  there,  so  that  it  no  longer 
changes  its  level  with  the  changes  in  the  patient's 
posture.  This  differentiates  the  malady  from 
hydrothorax.  In  the  fluid  are  found  white  and 
red  blood-cells,  fibrin,  albumin,  endothelial  cells, 
sometimes  cholesterin  and  uric  acid  crystals.  Its 
composition  is  that  of  blood-serum,  simple  or  con- 
centrated. 

If  copious  enough,  the  fiuid  causes  compression 
of  the  lung,  pushes  the  heart  and  mediastinum 


74  THE  DISEASES   OF  THE  RESPIRATORY   ORGANS. 

towards  the  opposite  side  and  the  diaphragm,  liver 
or  stomach  downwards. 

The  causes  are  similar  to  those  of  fibrinous 
pleurisy.  Exposure  to  cold  or  wet  and  traumat- 
isms are  excitants.  Many  cases  are  due  to  tuber- 
culosis, primary,  or  following  the  same  infection 
in  the  lungs  or  elsewhere.  Pleurisy  also  occurs 
with  rheumatism,  pneumonia,  typhoid  fever  and 
pericarditis,  or  nephritis,  cancer  and  cirrhosis  of 
the  liver. 

Symptoms. — In  secondary  pleurisy  the  attack 
may  be  masked  by  the  primary  disease.  In 
primary  attacks  the  onset  is  also  often  insidious, 
rarely  sudden,  with  chills  and  high  fever.  The 
stitch  in  the  side  follows,  becoming  worse  on  ex- 
ertion or  drawing  a  long  breath.  Dyspnea  fol- 
lows, with  voluntary  restraint  of  breathing  and 
coughing.  The  sputa  are  scanty,  mucous,  some- 
times blood-streaked.  The  fever  is  of  medium  in- 
tensity, higher  in  evenings,  the  pulse  rapid  and 
small.  In  latent  forms  there  may  be  a  decline  in 
health  for  weeks  before  the  malady  is  recognized, 
with  anorexia  and  emaciation,  or  headache  and 
dyspeptic  symptoms.  Eemissions  may  occur,  with 
relapses,  each  leaving  the  level  of  the  effusion 
higher,  until  the  whole  sac  is  full  of  serum,  the 
lung  pressed  solid. 

The  stitch  is  not  noted  in  the  insidious  form, 
and  disappears  when  the  effusion  separates  the  in- 


PLEURISY.  75 

flamed  surfaces.  The  breathing  is  restrained 
before  effusion,  shallow  and  somewhat  hurried 
afterwards,  intense  if  the  effusion  is  profuse  and 
rapidly  thrown  out.  But  fever  has  as  much  to  do 
with  the  production  of  dyspnea  as  has  the  actual 
pressure  on  the  lungs.  Cyanosis,  however,  de- 
pends solely  on  the  latter.  The  cough  is  dry  unless 
bronchitis  coexists.  The  fever  is  not  high,  is 
usually  regular  in  range,  and  subsides  by  lysis. 
On  the  pleuritic  side  it  is  somewhat  higher  than 
on  the  other.  The  pulse  corresponds  with  the 
fever;  the  volume  and  tension  are  lowered.  Pres- 
sure on  the  heart  and  great  vessels  may  occasion 
irregularity.  The  appetite  is  poor,  the  bowels  con- 
fined. The  urine  is  lessened,  the  specific  gravity 
high  until  absorption  begins,  when  diuresis  occurs. 
The  physical  signs  are  the  same  as  in  plastic 
pleurisy,  except  that  in  the  serous  form  there  is 
dullness  corresponding  with  the  effusion,  the  in- 
tercostal spaces  bulge,  the  respiratory  movements 
are  absent.  Tactile  fremitus  is  lost  early.  The 
motion  of  the  affected  side  on  respiration  is  almost 
nil,  while  the  other  side  shows  the  usual  expansion.. 
The  dullness  caused  by  the  effusion  is  only  noted 
posteriorly  in  slight  effusions,  and  rises  higher 
there  than  in  front.  If  not  confined  by  adhesions 
the  fluid  changes  with  change  of  posture.  If  it 
ascends  to  the  lower  border  of  the  third  rib,  the 
note  is  tjrmpanitic  above  it  (Skoda's  resonance). 


76  THE  DISEASES   OF  THE   RESPIRATORY   ORGANS. 

In  large  exudations  the  cracked-pot  sound  may  be 
found  below  the  clavicle,  and  ^^illiams'  tracheal 
tone"  may  be  obtained.  Auscultation  reveals  dry 
friction  sounds  in  the  first  stage. 

When  effusion  occurs  this  is  lost,  the  vesicular 
murmur  weakens  and  even  disappears,  while  if  the 
lung  is  wholly  compressed  the  bronchial  sounds 
may  be  lost;  if  not,  there  is  broncho-vesicular 
breathing  above  the  fluid.  The  vocal  resonance 
may  simulate  the  bleating  of  a  goat  (Laennec's 
egophony). 

During  absorption  the  distention  subsides,  and 
respiratory  movement  returns.  If  the  lung  does 
not  re-expand  the  intercostal  and  clavicular  spaces 
sink,  the  ribs  are  drawn  together,  the  spine  curves 
laterally,  the  heart  is  drawn  over,  and  this  per- 
haps, with  bronchiectasis  and  emphysema,  fills  up 
the  vacuum.  As  the  fluid  recedes,  if  the  lung  ex- 
pands the  normal  sounds  gradually  reappear,  and 
displaced  organs  resume  their  proper  locations. 
Friction  sounds  may  remain  for  a  long  time.  The 
lower  part  of  the  lung  may  remain  compressed. 

Tubercular  pleurisy  may  be  acute,  subacute  or 
chronic;  primary,  or  secondary  to  tubercle  in  the 
lungs,  peritoneum  or  elsewhere.  The  effusion  is 
often  sanguineous.    Eecovery  is  possible. 

Diaphragmatic  pleurisy  occurs  with  acute 
symptoms,  moderate  effusion,  pain  along  the  tenth 
rib,  increased  by  deep  inspiration  and  by  pressure 


PLEURISY.  77 

over  the  insertion  of  the  diaphragm  into  the  tenth 
rib,  dyspnea,  cough,  and  nausea  or  vomiting.  The 
fever  is  unusually  high,  the  anxiety  extreme.  If 
the  effusion  is  purulent  the  lower  intercostals 
bulge,  with  edema  later. 

Local  pleurisy  may  occur  with  a  moderate  effu- 
sion, encysted  by  adhesions,  in  any  part  of  the 
chest.  The  diagnosis  may  be  assisted  by  aspirat- 
ing. 

Interlobar  pleurisy  may  cause  encapsuled  col- 
lections between  the  lobes.  It  is  more  frequent 
in  the  right  lung  between  the  upper  and  middle 
lobes.  The  ailment  may  be  denoted  by  the  appear- 
ance of  pus  in  the  sputa,  the  previous  S3Tnptoms 
having  been  indeterminate. 

Hemorrhagic  pleurisy  occurs  from  tubercular 
infection,  cancer,  nephritis,  hepatic  cirrhosis, 
septic  debility,  old  age  and  alcoholism,  and  per- 
haps without  detectable  cause. 

DiAGiirosis. — Pneumonia  begins  with  a  chill 
thoracic  ache,  rusty  sputa  (at  first  gray),  intense 
fever,  ending  by  crisis,  marked  prostration,  flush 
on  one  cheek,  herpes,  pneumococcus  in  the  sputa ; 
signs  of  increased  tactile  fremitus,  crepitus  at  first, 
imperfect  dullness  in  second  stage,  bronchial 
breathing,  bronchophony,  and  yields  blood  on  as- 
piration. 

Pleurisy  shows  a  less  marked  onset,  stitch- 
pain,  cough    dry  and  repressed    from    pain,  no 


78  THE  DISEASES  OF  THE  RESPIRATORY   ORGANS. 

pneumococei  in  sputa  if  any  are  raised,  moderate 
fever,  ending  by  lysis,  some  debility  rather  than 
prostration,  face  pale,  no  herpes,  thorax  distended 
on  affected  side,  lessened  tactile  fremitus,  dullness 
absolute  over  effusion,  neighboring  organs  dis- 
placed, dullness  may  shift  on  change  of  posture, 
breath-sounds  absent,  vocal  resonance  less,  ego- 
phony,  friction  sounds  in  first  and  third  stages, 
aspiration  yields  serum. 

Tubercular  consolidation  has  a  different  history, 
more  fever,  rapid  decline,  the  tubercle  bacilli  in 
the  sputa. 

Hydrothorax  has  the  history  and  causes  of 
dropsy,  and  the  fluid  shifts  on  change  of  posture ; 
there  is  no  fever,  it  is  bilateral,  no  pain  or  fr.iction- 
sounds.  The  specific  gravity  of  the  fluid  is  below 
1015,  that  of  pleurisy  above  1017. 

Tumors  distend  the  thorax  partially,  not  be- 
ginning at  the  most  dependent  part,  the  tactile 
fremitus  and  vocal  resonance  are  higher,  the  his- 
tory differs,  there  are  no  friction-sounds  except 
from  accompanying  pleurisy.  Hepatic  tumors, 
cysts  or  abscesses  cause  dullness,  beginning  below 
but  at  a  limited  point,  and  at  all  stages  there  is 
usually  resonance  on  one  or  both  sides,  where  in 
pleurisy  there  would  be  dullness.  A  puncture  set- 
tles doubtful  cases. 

Pericardial  effusions  cause  urgent  dyspnea,  with 
feeble  heart-sounds,  the  heart  is  not  displaced,  the 


PLEURISY. 


dullness  is  in  front  rather  than  behind,  and  the 
history  of  rheumatism  may  be  had.  The  history 
may  separate  tuberculosis  from  other  forms  of 
pleurisy,  the  serum  may  be  examined  for  the 
bacillus  and  guinea-pigs  inoculated  with  it. 

There  is  no  definite  course  to  a  pleurisy.  The 
inflammation  may  last  one  to  three  weeks.  The 
effusion  is  usually  absorbed  fast  or  slowly,  much 
as  it  was  effused.  Large  effusions  may  persist  or 
develop  into  empyema.  The  absence  of  bacteria 
indicates  tuberculosis.  The  prognosis  in  simple 
serous  cases  is  good.  Death  sometimes  occurs  from 
a  sudden  and  copious  effusion. 

Treatment. — The  management  of  this  form  of 
pleurisy  is  identical  with  that  of  the  fibrinous 
form,  during  the  first  period.  We  have,  however, 
to  deal  here  with  a  bulky  effusion,  which  com- 
presses the  lung  and  may  permanently  destroy  its 
power  of  expansion.  The  question  arises,  how  to 
deal  with  this  effusion.  In  some  instances  the 
compression  has  been  relieved  in  a  few  days  and 
yet  the  lung  failed  to  unfold.  In  such  cases  it  is 
probable  that  there  has  been  an  exudation  inflam- 
mation in  the  carnified  lung-tissues,  permanently 
gluing  them  together.  On  the  other  hand,  such 
profuse  exudations  have  existed  for  many  weeks 
and  still  the  lung  resumed  its  functions. 

Paracentesis  thoracis  is  a  simple  and  harmless 
operation  when  aseptically  performed,   and  even 


80  THE  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

in  the  febrile  period,  when  the  effusion  is  so  bulky 
as  to  compress  the  lung  into  an  airless  mass,  it 
seems  wise  to  remove  a  portion  of  the  fluid.  In 
double  pleurisy,  or  when  respiration  is  seriously 
embarrassed,  or  signs  of  commencing  hyperemia 
appear  on  the  unaffected  side,  or  when  sjrricope, 
orthopnea,  cyanosis  or  murmurs  in  the  displaced 
heart  occur,  enough  fluid  should  be  withdrawn  to 
give  reKef.  No  attempt  should  be  made  to  with- 
draw all  the  effusion,  as  this  would  bring  inflamed 
pleura  together  and  increase  the  pain  and  fever. 

"When  the  fever  has  subsided,  the  sooner  the  fluid 
is  aspirated  the  better.  No  good  object  is  obtained 
by  its  presence,  and  every  day  the  lung  remains 
compressed  adds  to  the  danger  of  permanent  dis- 
ability. When  a  goodly  portion  has  been  removed 
and  the  pressure  relieved,  absorption  usually  sets 
in.  If  the  lung  does  not  at  once  expand  some 
danger  would  ensue  by  removal  of  its  support. 
The  fluid  should  therefore  be  allowed  to  drain 
away  slowly  and  spontaneously,  not  solicited  or 
forced.  If  dyspnea,  incessant  cough,  sharp  pain 
or  a  sense  of  oppression  occur^,  the  needle  must  be 
at  once  withdrawn. 

The  aspirator  must  be  aseptic,  the  skin  washed 
with  soap,  ether  and  bichloride  solution  1  to  1000. 
Raise  the  arm  so  as  to  separate  the  ribs  and  insert 
the  needle  close  to  the  upper  border  of  the  rib. 
The  best  places  are  the  sixth  interspace  on  the 


PLEURISY.  81 

right,  the  seventh  on  the  left,  under  the  middle  of 
the  axilla;  or  just  below  the  outer  angle  of  the 
scapula  in  the  seventh  right  or  eighth  left  spaces. 
If  the  pleura  is  very  thick  or  a  mass  of  l3rmph  is 
struck  the  fluid  may  not  be  found  at  the  first 
puncture.  Larger  needles  are  required  as  the  fluid 
becomes  thicker.  From  four  to  twenty-four 
ounces  may  he  taken  at  one  time,  more  during  the 
febrile  stages  than  later. 


CHAPTER  XVIII. 

EMPYEMA. 

Sometimes  the  pleuritic  exudate  contains  pus; 
similar  to  ordinary  pus  unless  pulmonary  gan- 
grene is  present,  when  the  fluid  is  exceedingly 
fetid.  The  inflammation  is  more  intense  than  in 
common  pleurisies,  and  the  tissues  are  thickened, 
granular,  perforated  or  eroded.  The  altered  mem- 
branes consist  of  new  connective  tissue,  blood-ves- 
sels and  leucocytes.  Empyema  may  follow  ordi- 
nary pleurisy.  In  children  it  occurs  early  or  from 
the  first;  it  may  be  secondary  to  septic  fevers, 
result  from  invasion  of  the  pleura  by  cancer  or 
tubercle,  or  follow  penetrating  wounds.  The  or- 
ganisms most  frequently  met  are  micrococcus 
ianceolatus,  streptococcus,  staphylococcus  and 
tubercle  bacillus.  Pneumococcus  cases  are  milder. 
Leptothrix  occurs  in  putrid  effusions. 

Symptoms. — There  may  be  an  acute  onset, 
chills,  fever,  prostration,  severe  pain  made  worse 
by  breathing  or  exercise.  If  gangrenous,  the  pros- 
tration soon  becomes  extreme  and  death  occurs  in 
a  few  weeks.  Often  the  acute  symptoms  subside  in 
a  week  and  chronic  symptoms  arise.  Dyspnea  is 
apt  to  be  more  prominent  than  pain  and  cough; 
but  the  evidences  of  sepsis — irregular  chills,  fever 


EMPYEMA. 


and  sweating,  rapid  wasting,  etc. — soon  predom- 
inate. Peptonuria  is  a  diagnostic  evidence  of 
value,  though  simply  indicative  of  suppuration, 
not  excluding  tubercle,  etc.  The  same  may  be  said 
of  indicanuria.    Leucocytosis  is  always  present. 

The  pus  may  discharge  through  the  lung,  caus- 
ing pneumopyothorax ;  less  often  through  the 
skin,  esophagus,  pericardium,  stomach  or  peri- 
toneum. 

The  signs  are  those  of  ordinary  pleurisy.  The 
chest-wall  may  become  edematous,  the  pus  point- 
ing and  discharging  externally.  The  pus  does 
not  change  level  with  posture  as  readily  as  a  serous 
effusion.  Baccellfs  sign  is  the  transmission  of  the 
whispered  voice  through  a  serous  collection,  not 
through  pus.  The  cardiac  pulsations  are  some- 
times transmitted  through  empyema,  rarely 
through  a  sero-fibrinous  exudation.  The  necessary 
elements  are  a  copious  effusion,  relaxed  thoracic 
wall,  and  a  strong  heart-beat.  It  is  usually  on  the 
left,  front  and  side. 

Empyema  is  diagnosed  from  ordinary  pleurisy 
by  the  rapid  decline  and  other  evidences  of  sepsis, 
and  by  the  aspirator.  Pulsating  empyema  does 
not  appear  in  the  location  of  aortic  aneurism,  there 
is  neither  heave  nor  bruit,  and  the  constitutional 
symptoms  differ  totally. 

The  prognosis  depends  first  on  the  cause,  second 
on  the  treatment,  third  on  luck.    Death  may  occur 


84  THE  DISEASES  OF   THE  RESPIRATORY   ORGANS. 

from  the  discharge  of  pus  in  a  fatal  way,  from 
exhaustion,  or  from  intercurrent  or  complicating 
disease.  Children  recover  better  than  adults.  Re- 
covery occurs  only  with  gradual  adhesion  of  the 
pleura,  obliterating  the  cavity,  and  subsequent  re- 
traction. 

Treatment. — In  children  it  may  be  allowed 
three  weeks  for  nature's  cure.  In  adults  a  large 
empyema  should  be  aspirated  at  once.  Following 
pneumonia,  it  is  best  to  make  a  free  incision  and 
drain.  Open  in  the  fifth  or  sixth  intercostal  space, 
outside  the  nipple,  the  incision  being  an  inch  long. 
Estlander's  rib  resection  is  not  necessary  if  free 
drainage  can  be  secured  without  it.  If  the  pus 
is  offensive  the  cavity  should  be  irrigated  antisep- 
tically;  otherwise  insert  iodoform  gauze.  Expan- 
sion of  the  lung  is  favored  by  systematic  exercise. 
James'  method  is  to  have  the  patient  force  water 
from  one  bottle  to  another  by  means  of  tubes,  the 
effort  being  gradually  increased.  It  is  best  to  use 
boric  acid,  permanganate  or  aromatic  antiseptic 
solutions  for  irrigation,  as  bichloride,  carbolic  acid 
and  peroxide  are  unsafe. 

Every  effort  should  be  taken  to  keep  up  the 
strength,  by  rich  feeding,  etc.  The  arsenates  of 
iron  and  quinine  each  one  centigram  (gr.  1-6), 
and  of  strychnine  two  milligrams  (gr.  1-30), 
should  be  given  every  two  to  four  hours,  with 
calcium  sulphide  six  centigrams    (gr.   1)    seven 


EMPYEMA. 


times  a  day  to  restrain  suppuration.  Whether  the 
latter  would  cure  without  operation  I  am  not  pre- 
pared to  say,  but  it  is  the  most  effective  antagonist 
of  suppuration-germs  yet  produced. 


CHAPTER  XIX. 
PNEUMOTHORAX. 

If  air  be  admitted  to  the  pleura  the  lung  col- 
lapses into  a  firm  mass,  attaches  to  the  bronchus, 
the  air  fills  the  sac,  obliterating  the  intercostal 
depressions,  and  giving  a  clear,  tympanic  percus- 
sion note  over  the  entire  side,  with  no  respiratory 
sounds  whatever.  If  the  admitted  air  is  sterile, 
it  is  rapidly  absorbed;  if  it  carries  the  germs  of 
suppuration,  pyopneumothorax  develops. 

The  causes  of  pneumothorax  are :  Perforation 
from  a  tuberculous  cavity;  gangrene;  broncho- 
pneumonia; glandular  suppuration;  abscess; 
cysts;  rupture  of  air-cells  by  strain;  perforating 
empyema ;  cancer  or  esophageal  abscess ;  bronchiec- 
tasis ;  cancer  or  ulcer  of  stomach  or  colon.  Gases 
may  be  developed  in  the  pleura  by  certain  organ- 
isms. Wounds  may  penetrate  the  pleura. 

The  occurrence  of  pneumothorax  is  attended  by 
sudden  and  intense  dyspnea  and  pain,  sometimes 
cyanosis,  hurried  breathing,  the  pulse  weak  and 
fast,  cold  sweat,  and  collapse,  in  which  death  may 
occur.  The  temperature  falls  below  normal  and 
then  rapidly  rises  as  pleurisy  develops.  It  is  usually 
hectic,  as  suppuration  ensues  edema  of  the  hand  on 
the  affected  side  sometimes  occurs,  soon  disappear- 


PNEUMOTHORAX.  87 

ing.  As  fluid  collects  in  the  pleura,  when  the 
patient  shakes  the  chest  splashing  is  heard,  the 
"Hippocratic  succussion/'  or  "metallic  tinkling," 
from  drops  falling  into  the  fluid.  "Wintrich's  sign" 
is  a  change  in  the  pitch  of  the  percussion  sound 
as  the  mouth  is  open  or  closed.  The  "coin-test" 
is  considered  pathognomonic.  A  coin  is  held  on  the 
front  of  the  chest  and  tapped  with  another  coin, 
while  the  examiner's  ear  is  applied  to  the  back  of 
the  thorax,  when  he  hears  the  intensified  echo  of 
the  sound  produced.  The  cracked-pot  sound  and 
Wintrich's  sign  are  more  frequent  in  a  large  pul- 
monary cavity  than  in  pneumothorax.  The  former 
does  not  dislocate  the  organs  and  has  no  response 
to  the  coin  test  or  succussion. 

Gastric  flatulence  has  been  mistaken  for  pneu- 
mothorax. Subphrenic  abscesses  containing  air 
occur,  mostly  on  the  right  side,  from  gastric  ulcer. 
Diaphragmatic  hernia  results  from  injury  or  con- 
genitally,  and  is  recognized  by  its  cause,  rumbling, 
and  possible  reduction.  Emphysema  is  slow  in  de- 
velopment and  has  none  of  the  specific  signs  men- 
tioned. 

The  prognosis  depends  on  the  cause. 

Treatment. — Combat  shock  and  collapse  with 
glonoin  and  atropine,  one-fourth  milligram  (gr. 
1-250)  each,  every  fifteen  minutes  till  reaction 
occurs;  relieve  pain  by  morphine,  if  necessary. 
Great  dyspnea  may  indicate  the  wisdom  of  draw- 


88  THE  DISEASES   OF   THE   RESPIRATORY    ORGANS. 

ing  off  the  air  with  an  aspirator,  but  if  the  malady 
is  due  to  a  wound  that  is  capable  of  healing  it  is 
better  to  leave  the  lung  collapsed  till  this  has  taken 
place.  Murphy's  experiments  have  shown  that 
sterile  gases  are  rapidly  absorbed  from  the  pleura. 
If  suppuration  occurs  the  treatment  is  that  of  em- 
pyema. 


CHAPTER  XX. 

PNEUMONIA. 

A  specific  fever  caused  by  the  invasion  of  the 
lung  by  the  pneumococcus,  or  micrococcus  lance- 
olatus.  The  disease  affects  one  or  more  lobes,  in 
one  or  both  lungs,  commencing  at  the  apex  of  each 
lobe  and  extending  toward  the  pleural  surface, 
with  variable  rapidity.    There  are  three  stages. 

Hyperemia — The  tissue  is  dark-red,  firm,  heavy, 
but  floats  in  water,  the  air-cells  distended,  and  if 
any  lobules  are  collapsed  they  can  be  inflated  by 
the  bronchus.  Extravasation  may  occur  near  the 
pleura  surface.  The  epithelium  is  swollen,  cap- 
illaries engorged,  air-cells  and  bronchioles  filled 
with  epithelium,  red  cells  and  some  leucocytes. 

Red  Hepatization — The  lung  is  solid,  airless; 
liver-like,  mahogany  color,  dry,  mottled,  swollen, 
too  heavy  to  float,  not  inflatable,  friable,  the  air- 
cells  and  bronchioles  filled  with  fibrinous  plugs 
that  give  the  cut  surface  a  granular  appearance. 
The  pleural  surface  is  covered  with  fibrin.  The 
fibrinous  plugs  contain  red  pus,  and  epithelial 
cells.  The  connective  tissue  is  sometimes  filled 
with  leucocytes  and  fibrils,  the  vessels  are  pervious 
and  pneumococci  are  to  be  found — sometimes 
streptococci  and  staphylococci. 


90  THE  DISEASES   OF  THE   RESPIRATORY   ORGANS. 

Gray  Hepatization — As  the  exudate  becomes 
fatty  the  color  pales,  the  tissue  softens,  the  exudate 
liquefies,  and  numerous  leucocytes  invade  the  air- 
cells.  Resolution  sets  in  and  the  exudate  is  largely 
removed  by  the  lymphatics.  But  the  attack  may 
not  terminate  so  favorably.  Suppuration  may 
occur,  pus  cells  infiltrating  the  tissues  and  air- 
cells,  possibly  ending  in  abscess  from  streptococcal 
conquest  of  the  enfeebled  tissues.  The  abscess  may 
discharge  or  caseate.  (See  Pulmonary  Abscess.) 
Gangrene  is  a  rare  ending.  Induration  sometimes 
ensues,  the  alveoli  filled  with  new  connective  tis- 
sue. 

The  heart-muscle  is  pale,  the  blood  highly  co- 
agulable;  pericarditis,  endocarditis,  desquamative 
and  interstitial  nephritis,  and  rarely  meningitis, 
may  complicate. 

The  spleen  is  congested,  the  stomach  and  bow- 
els catarrhal. 

Etiology. — The  pneumococcus  of  Fraenkel  is 
lance-shaped,  occurs  in  pairs,  is  often  found  in  the 
nose  and  mouth  of  healthy  persons  and  especially 
in  those  who  have  had  pneumonia.  It  may  be  dem- 
onstrated in  the  sputa  by  treating  a  cover-slip  prep- 
aration with  glacial  acetic  acid,  washing  off  th^ 
acid,  and  adding  anilin  oil  and  gentian  violet, 
poured  off  and  renewed  several  times.  Other  or- 
ganisms are  found  in  the  sputa,  such  as  Fried- 
laender^s   and  Eberth's  bacilli,  influenza  bacilli, 


PNEUMONIA.  91 

etreptococci,  etc.,  and  it  is  probable  that  they  also 
cause  the  disease  we  term  pneumonia,  alone  or  with 
the  pneumococcus. 

Infection  occurs  by  inhalation  of  the  causal 
micro-organisms,  the  pneumococcus  perhaps  open- 
ing the  way  for  the  others.  Predisposing  causes 
are,  1,  endemic  influence,  certain  buildings  be- 
coming infected;  2,  epidemic  influence,  possibly 
direct  contagion;  3,  season,  the  cold  and  wet  of 
winter;  4,  exposure  to  cold,  lowering  the  vitality 
of  the  tissues  to  a  point  when  the  ever-present 
pneumococcus  can  successfully  attack  them ;  5,  age, 
the  extremes  of  life  being  most  liable ;  6,  sex,  whose 
only  influence  is  as  to  relative  exposure,  males 
being  most  frequently  attacked;  7,  bad  hygiene, 
the  crowded  city  slums  showing  the  most  and  worst 
eases ;  8,  alcoholism ;  9,  typhoid,  measles  and  other 
septic  fevers  are  sometimes  complicated  with  pneu- 
monia ;  10,  it  occurs  as  a  terminal  malady  to  finish 
off  sufferers  in  the  last  stages  of  chronic  nephritis, 
diabetes,  cancer,  heart-disease,  etc. 

Climate  has  some  influence  on  pneumonia,  it  be- 
ing somewhat  more  fatal  in  the  south,  where  the 
vital  resistance  is  less  than  in  those  who  have  been 
toughened  by  exposure  to  the  northern  winters. 
But  in  every  part  of  our  country,  north  and  south, 
in  the  hot  moist  air  of  Florida  and  the  thin  dry  at- 
mosphere of  the  Eockies,  the  bleak  barrens  of 
Canada  and  the  rich  jungles  of  the  Mexican  coast, 


TABLE   OF  DIFFERENTIAL   DIAGNOSIS. 


PNEUMOCOCCUS 

ACUTE 

PNEUMONIA. 

TUBERCULOUS   PNEUMONIA. 

PLiEURIST. 

Previous 

Exposure  to   co-Id  or  infec- 

Inherited tendency  or  prior 

Traumatism. 

history. 

tion;  may  have  had  pneu- 

tuberculoses. Exposure  to 

Exposure  to 

monia  before. 

infection. 

cold. 

Onset. 

Abrupt    chill,    followed    by 

Gradual,  as  if  catching  cold, 

Chilliness  for 

fever  quickly  rising  high, 

repeated  rigors. 

days. 

convulsions  in   children. 

Febrile  type. 

Continuous;  ends  by  crisis. 

Remittent,     moderating     or 

Continuous, 

ending  by  lysis. 

moderate, 
ceas  ing  by 
lysis. 

Sweating. 

None,      until      profuse      at 

Free,      repeated      whenever 

crisis. 

fever  falls. 

Herpes. 

Common. 

None. 

None. 

Wasting. 

Not  marked. 

Rapid  and  great. 

Pain. 

Diffuse  aching. 

Stitch  comes  late. 

Acute  stitch 
localized. 

Relation,  pulse 

Much  disturbed. 

Less  modified. 

respiration. 

Cougb. 

Severe. 

Severe. 

Dry,  painful, 
suppressed. 

Sputa. 

Gray    and    adhesive,     then 

Streaked     or    stained    with 

None,   or 

rusty;  prune- juice  later  in 

blood,      purulent,      freer: 

catarrhal. 

bad  cases. 

when     lung    is    breaking 
down     contain     branched 
elastic  fibers. 

Bacteriology. 

Pneumonia  diplococci. 

Tubercle  bacilli. 

None. 

Aspirator. 

Thick  blood. 

Blood,  later  debris. 

Serum. 

Duration 

A  week,  more  or  less. 

Longer,  indefinite. 

Indefinite,  may 

of  fever. 

J)e  none,  or 
subside  on 
effusion. 

Prostration. 

Little. 

Marked. 

Moderate. 

Location. 

Base  of  lung  usually. 

Apex  usually. 

Lower  poster- 
ior part  of 
one  pleura. 

Face. 

Flushed    cheek    on    affected 
side,  congested. 

Hectic  towards  evening. 

Pale  and 
anxious. 

Extension. 

Rapidly  to  next  lobes. 

In  time  to  base  and   other 

May  fill  up 

apex. 

pleura  from 
below. 
Flatness,  heart 

Percussion. 

Lobe  consolidation,   subsid- 

Consolidation, part  of  lobe, 

ing  after  crisis;    dullness 
not  absolute. 

followed  by  cavity. 

displaced ; 
line  of    dull- 
ness changes 
withposition. 

Auscultation. 

Crepitus,      then      bronchial 

Fine      crepitus,      becoming 

Bronchial 

breathing,  after  crisis  rale 

coarser;  variety  of  rales; 

breathing,  ' 

redux   (subcrepitant). 

cavity-gurgling. 

sound  remote, 
no    rales.* 

Sequences. 

Not  tubercular. 

Tuberculosis  elsewhere. 

Little  or  none. 

Vocal 

Bronchophony. 

Oegophony. 

resonance. 

Leucocytosis. 

Pronounced. 

Slight,  until  suppuration. 

Inspection. 

Not  as  in  pleurisy. 

Not  as  in  Pleurisy. 

Thorax  dis- 
tended, no 
respiratory 
move  ment 
over  effusion. 

Palpation. 

Tactile  fremitus  marked. 

Little  or  no 
fremitus. 

9S 


*  Friction  rub  in  first  stage  and  late. 


PNEUMONIA.  93 

pneumonia  prevails  as  one  of  the  principal  causes 
of  death.  The  causal  agencies  are  omnipresent. 
One  attack  predisposes  to  another,  and  this  is  eas- 
ily comprehended  when  we  find  the  pneumococcus 
a  life-long  guest  in  the  mouth,  ready  at  any  time 
to  attack  its  host  again,  when  his  vitality  is  low. 

Pasteur  found  it  impossible  to  inoculate  the 
cock  successfully  with  the  pneumococcus,  the  bird's 
normal  temperature  being  higher  than  man's.  But 
when  he  was  placed  in  a  refrigerator  till  his  tem- 
perature fell  to  98,  the  pneumonic  infection  took 
effect.  This  throws  light  on  the  attacks  following 
exposure  to  cold,  especially  when  the  vital  resist- 
ance is  paralyzed  and  the  body  heat  reduced  by 
alcohol. 

The  serum  from  the  blood  of  convalescents  con- 
tains an  antitoxin  which  cuts  short  the  disease  in 
others,  inducing  crisis.  The  pneumococcus  gener- 
ates pneumotoxin,  which  causes  fever,  and  acting 
on  the  body  albumin  generates  an  antipneumo- 
toxin,  which  neutralizes  the  toxin  in  the  blood  as 
it  is  formed.     It  has  not  yet  been  isolated. 

Symptoms. — Sometimes  when  one  has  ^'taken 
cold"  from  exposure  there  are  several  days  of  ma- 
laise, illness  without  demonstrable  disease  of  the 
lung.  The  patient  knows  he  has  contracted  a  mal- 
ady, but  apparently  it  has  not  yet  established 
itself  at  any  one  locality.  In  such  cases  it  is  prob- 
able  that   a   slight   pneumococcus   invasion    has 


94 


THE  DISEASES    OF   THE   RESPIRATORY   ORGANS'. 


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PNEUMONIA.  95 


taken  place  at  the  apex  of  one  lobe,  the  micro-or- 
ganisms being  so  few  in  number  that  repeated 
hatchings  of  new  broods  are  necessary  before  they 
can  produce  typical  symptoms.  Meanwhile  the 
infection  is  spreading  slowly  up  the  lobe,  and  in 
due  time  the  identity  of  the  disease  is  established. 

In  other  cases  the  attack  opens  abruptly  with  a 
chill,  followed  by  fever  up  to  104°  F.,  oppres- 
sion of  the  chest,  substernal  soreness,  rapid  pulse, 
the  skin  hot  and  dry,  the  cheek  on  the  affected 
side  showing  a  curious  red  flush,  headache,  weak- 
ness, anorexia,  third,  very  often  delirium.  Deep 
inspirations  do  not  cause  acute  stitching  pain  until 
the  disease  has  spread  through  the  entire  lobe  to 
the  pleura.  Respirations  are  hurried  and  shallow, 
30  or  more  per  minute.  Cough  is  irritative,  dry, 
painful,  the  sputa  at  first  scanty,  gray  and  sticky, 
soon  becoming  rusty,  and  stained  with  bright  blood 
when  collateral  hyperemia  develops.  Little  chil- 
dren have  a  peculiar  catch  in  the  breathing,  just 
before  expiration,  which  is  quite  characteristic. 
There  may  be  gastro-intestinal  catarrh,  at  first  or 
at  any  time  later,  with  anorexia,  nausea,  vomiting 
or  diarrhea.  If  marked,  this  is  a  dangerous  ele- 
ment. 

The  patient  lies  on  the  affected  side,  mouth 
open,  lips  stained,  eyes  bright,  speech  restrained  by 
the  painful  and  rapid  breathing.  In  alcoholics 
the  delirium  may  simulate  delirium  tremens.  An 


96  THE  DISEASES   OF  THE   RESPIRATORY   ORGANS. 

eruption  of  herpes  often  appears  about  the  nose 
or  lips.  The  fever  rises  as  night  approaches,  the 
daily  range  being  about  one  degree.  The  pulse 
runs  to  100,  being  slow  in  comparison  to  the  fever. 

The  malady  continues  in  this  manner  until  the 
fifth,  seventh  or  ninth  day,  when  in  favorable 
cases  crisis  occurs,  with  a  sudden  fall  of  temper- 
ature below  normal,  profuse  sweating  or  diarrhea, 
great,  sometimes  fatal  prostration,  and  relief  from 
the  dyspnea,  cough  and  other  distress.  Conval- 
escence goes  on  rapidly,  but  the  evidences  of  con- 
solidation may  be  detected  for  weeks  after  the 
crisis. 

In  other  cases  crisis  does  not  occur,  but  puru- 
lent infiltration  supervenes,  the  symptoms  decline 
by  lysis,  convalescence  is  protracted,  and  the  pa- 
tient recovers  with  more  or  less  damage  to  the 
lung;  perhaps  none,  perhaps  some  fibrosis  or  at- 
rophy. 

Respiration — The  patient  breathes  from  24  to 
60,  children  90  or  more,  times  per  minute.  He 
pants,  restrains  the  thoracic  movement,  and  suf- 
fers dyspnea  in  proportion  toi  the  fever.  When 
several  lobes  are  affected  the  collateral  fluxion  in 
the  remainder  renders  the  oppression  almost  un- 
bearable. Bronchial  catarrh  coexists  to  some  ex- 
tent. The  rate  of  the  respiration  to  the  pulse 
is  1  to  1.5  or  2,  instead  of  1  to  4  as  in  health.  The 
pain  develops  with  pleural  involvement,  in  several 


PNEUMONIA.  97 

hours  or  more,  and  lasts  three  days.  It  is  made 
worse  by  coughing.  The  cough  is  dry,  harsh  and 
constant,  repressed  after  pleurisy  develops,  but 
may  be  much  less  annoying  in  the  aged,  in  alcohol- 
ics and  when  delirium  is  marked. 

The  sputa  are  at  first  gray  and  adhesive,  becom- 
ing blood-stained  or  rusty  in  a  few  hours,  and 
muco-purulent,  abundant  and  thinner  at  the  crisis. 
In  aged  and  prostrate  subjects  it  resembles  prune- 
juice.  If  the  collateral  fluxion  is  marked  it  is 
frothy  and  bright  bloody ;  if  edema  develops  it  be- 
comes serous.  Aged  patients  are  apt  to  swallow 
it  and  have  to  be  compelled  to  cough  up  ^''from  the 
bottom  of  the  lungs"  to  obtain  enough  for  inspec- 
tion. Eed  cells,  pus  cells,  epithelium,  fibrin  casts 
and  the  pneumococcus,  may  be  found  by  the  mi- 
croscope. 

Fever — The  temperature  rapidly  rises  to  104° 
or  more,  fluctuates  a  degree  daily,  and  drops  rap- 
idly to  below  normal  at  crisis.  Children  may  have 
an  initial  convulsion  instead  of  a  chill.  Aged  and 
weakly  persons  may  have  lower  fever.  An  attempt 
at  crisis  (pseudo-crisis)  may  precede  the  true  crisis 
a  day  or  more.  Hyperpyrexia,  105°  to  107°,  may 
precede  crisis,  which  is  more  apt  to  come  by  night. 
Febrile  rises  may  occur  during  convalescence,  from 
slight  causes,  such  as  an  unpleasant  visitor,  too 
heavy  a  meal,  etc.     Failure  of  crisis  to  appear  on 


98  THE  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

time  may  indicate  a  complication,  or  purulent  in- 
filtration. 

Circulation — The  pulse  runs  about  100  and  if 
above  120  indicates  danger,  as  threatened  heart- 
failure.  This  is  due  to  the  fever,  to  the  increased 
task  of  the  heart  in  driving  the  blood  through  the 
lessened  number  of  capillaries  in  the  non-pneu- 
monic lobes,  themselves  engorged  by  the  collateral 
hyperemia,  and  to  the  decreased  nutrition  of  the 
heart  from  the  abstraction  of  fibrin  from  the  blood 
and  from  the  interference  with  nutrition.  Peri- 
carditis sometimes  occurs,  and  this,  or  previously 
existent  heart-disease,  increases  the  danger.  A 
small  rapid  pulse,  with  irregularity  and  dicrotism, 
betoken  danger.  If  full  and  bounding  the  tension 
is  low.  Increased  tension  in  the  pulmonary  vessels 
accentuates  the  pulmonary  sound  (second  sound, 
heard  in  the  left  second  intercostal  space,  an  inch 
from  the  sternum).  If  the  right  ventricle  weak- 
ens, dilatation  results. 

Leucocytosis  is  marked,  continuing  until  the 
true  crisis.  Polynuclear  forms  of  white  cells  pre- 
vail during  fever,  diminishing  as  the  eosinophiles 
multiply.  The  red  cells  and  hemoglobin  decrease 
rapidly  after  the  crisis.    The  blood-plates  increase. 

Nervous  System — Headache  occurs  at  the  start 
and  may  persist.  Convulsions  may  be  present 
in  children.  Delirium  is  common.  If  the  fever  is 
high  it  is  of  maniacal  type,  while  in  septic  states 


PNEUMONIA.  99 

it  is  low,  muttering,  with  a  tendency  to  coma. 
Drunkards  exhibit  typical  mania  a  potUj  getting 
out  of  bed  to  kill  rats,  roaches,  etc.  When  fever 
rules  very  high  the  symptoms  may  simulate  men- 
ingitis. 

Skin — Herpes  of  the  nose  or  lips  is  of  some  im- 
portance in  diagnosis.  Profuse  sweats  mark  the 
crisis.  The  well-defined  flush  on  the  cheek  of  the 
affected  side  has  been  noted.  Urticaria  occurs 
sometimes. 

Digestive  System — The  tongue  is  dry  and  brown 
in  high  fever  and  great  debility,  covered  with  a 
uniformly  yellowish-white  coating  ordinarily. 
Marked  vomiting  or  diarrhea  may  indicate  infec- 
tion of  the  alimentary  canal,  and  such  cases  are  apt 
to  prove  fatal.  The  spleen  is  enlarged,  not  the 
liver. 

The  Urine — The  urine  is  scanty,  red,  of  high 
specific  gravity,  urea  and  uric  acid  in  excess,  chlo- 
rids  deficient.  Some  albumin  is  often  to  be 
found. 

Physical  Signs — First  stage.  Expansion  les- 
sened ;  costo-abdominal  breathing  in  double  pneu- 
monia; tactile  fremitus  slightly  increased;  per- 
cussion normal  or  briefer,  higher  pitched  or  tym- 
panitic; crepitant  rales,  vesicular  sounds  weak 
over  affected  lobe,  exaggerated  over  healthy  lobes. 

Second  stage.  Little  expansion  over  affected 
side,  increased  on  unaffected;  vocal  fremitus  in- 


100 


THE   DISEASES    OF    THE   RESPIRATORY    ORGANS. 


creased  usually,  friction  sounds  often;  percussion 
dullness  over  affected  lobes  posteriorly,  tympanitic 
anteriorly,  Skoda's  resonance  above  affected  lobe; 
bronchial  breathing,  bronchophony,  somethimes 
egophony,  subcrepitant  rales  from  bronchitis,  fric- 
tion from  pleurisy. 

Third  stage.  Expansion  returning,  fremitus  les- 


LOBAR  PNEUMONIA. 


Diplococcus   pneumoniae. 
Primairy. 

Onset  abrupt:  in   good  health. 

High  fever,  continuous;  crisis 
from    fifth    to    ninth    day. 

Sputa  gray,  then  rusty,  sticky; 
later  in  bad  cases,  prune- 
juice. 

Rapid  breathing,  moderate 
dyspnea  and  cyanosis. 

Signs  of  consolidation,  catarrh 
secondary. 

Unilateral,  usually  lobar  cir- 
cumscribed. 

Definite  course,  convalescence 
follows,  crisis  usually  com- 
plete. 

Not  apt  to  become  tubercular. 


BRONCHO-PNEUMONIA,    OR 
CAPILLARY      BRONCHITIS. 


Streptococci    and    many    other 

organisms. 
Follows     bronchitis,      measles, 

pertussis. 

Gradual  onset   from   cold. 

Fever  less,  irregular,  ends  by 
lysis,  no  set  duration. 

Sputa  gray,  sticky,  blood- 
stained. 

Dyspnea  and  cyanosis  marked, 

breathing  shallow. 
Catarrhal    signs     predominate. 

Bilateral;  not  limited  to  lobes; 
diffuse. 

Indefinite,  atelectasis  may  re- 
main permanently. 

Apt  to  become  tubercular,  may 
be  so  from  start;  bacilli  and 
later  elastic  fibers  then  ap- 
pear in  the  sputa. 


sening,  dullness  slowly  disappearing,  crepitant  rale 
redux,  coarser  than  in  the  first  stage  as  the  ex- 
udate is  softening;  bronchial  breathing,  gradually 
replaced  by  vesicular  sounds. 

Complications. — Pleurisy,  usually  fibrinous,  is 
always  present  when  the  pneumonia  reaches  the 


PNEUMONIA. 


101 


pleura.  If  the  pleuritic  symptoms  are  prominent 
the  malady  is  termed  plcuro-pueumonia.  Em- 
pyema may  supervene.  Acute  bronchitis  may  co- 
exist. Collateral  fluxion  may  occasion  edema,  the 
dyspnea  reaching  its  highest  point  and  the  patient 
dying  if  not  promptly  relieved.  Pericarditis  may 
result  from  extension  in  left  pneumonias.     It  is 


TYPHOID    FEVER. 


Prodromes. 

Onset  gradual. 

Little  pain. 

Depression  pro- 
gressive. 

Typical  fever 
course,  yielding 
slowly. 

Nervous  symp- 
toms of  debility. 

Little  catarrh. 

Eruption       like 

flea-bites. 
Muscle   aches. 

Typhoid  bacilli. 


PNEUMONIA. 


Exposure  to   cold 
and  wet. 

Abrupt  onset. 

Little   pain. 

Little  depression. 

Fever  obstinate. 


Nervous  phenom- 
ena  slight. 

Catarrhs  second- 
ary. 

Unilateral,  physi- 
cal signs. 

No  muscle  pain 
or  neuralgias. 

Pneumonia  Dip- 
lococci. 


CEREBRO-SPINAL 
INGITIS. 


MEN- 


Slower  onset. 

Exposure  to   cause. 
Intense  headache,  backache. 
Photophobia. 

Fever. 


Debility,  delirium. 
No  catarrh. 

Various    eruptions. 

Stiff  neck,  head  retracted. 

These  may  be  simulated  by 
influenza;  diagnosis  made 
only  by  finding  bacillus 
cellularis  in  cephalo- 
rachidian  fluid. 


more  frequent  in  children.  Endocarditis  is  more 
frequent,  especially  the  ulcerative  form;  it  is  be- 
tokened by  septic  fever,  chills  and  sweating,  with 
embolism  and  meningitis.  It  is  due  to  infection 
of  the  endocardium  by  the  pneumococcus.  Heart- 
clot,  venous  thrombosis  and  arterial  embolism,  and 


102  THE   DISEASES    OF    THE    RESPIRATORY    ORGANS. 

cerebral  embolism  occur  rarely.  Acute  suppura- 
tive meningitis  is  rare  but  grave  with  intense 
lieadaclie,  stiff  neck,  wild  delirium,  gradually  sub- 
siding in  coma.  Peripheral  neuritis,  parotitis, 
real  rheumatism  and  pneumococcal  arthritis 
have  been  noted.  Croupous  gastritis  is  rare, 
croupous  colitis  more  common.  Jaundice  is  fre- 
quent in  severe  forms.  Peritonitis  is  rare,  as  in 
acute  nephritis  of  a  mild  grade. 

Varieties. — Typhoid  pneumonia  is  a  form  char- 
acterized by  the  typhoid  state,  not  true  typhoid 
fever.  There  is  profound  prostration,  low  delir- 
ium, stupor  or  coma  vigil,  heart  feeble,  tongue 
brown,  fever  moderate,  skin  dusky  or  yellowish. 

Epidemic  pneumonia  is  often  malignant.  In 
^^arval  pneumonia"  the  general  symptoms  are 
mild,  the  signs  obscure. 

Latent  pneumonias  begin  at  the  lobar  apex  and 
never  reach  the  pleura.  In  emphysematous  sub- 
jects the  signs  may  be  masked. 

Migratory  pneumonia  extends  to  other  lobes  as 
each  recovers,  so  that  crisis  is  lost. 

Bilious  or  malarial  pneumonia  has  prolonged 
chills  and  paroxysmal  fever,  jaundice  and  vom- 
iting. 

In  the  aged  the  onset  is  insidious,  gastro-intes- 
tinal  symptoms  marked,  prostration  profound, 
fever  low  and  irregular,  local  symptoms  incon- 
spicuous.    Dullness,  shallow  bronchial  breathing 


PNEUMONIA.  103 

and  subcrepitant  or  serous  rales  are  to  be  detected. 
The  cough  may  be  wanting.  The  malady  is  very 
fatal. 

The  inhalation  of  ether  in  cold  weather,  espe- 
cially in  abdominal  operations,  is  often  followed 
by  pneumonia. 

Eelapses  are  very  rare. 

The  course  runs  from  three  days  to  as  many 
weeks  or  more,  the  average  duration,  according  to 
Osier,  being  ten  days.  Eesolution  may  be  post- 
poned to  the  tenth  week.  It  may  leave  the  lung- 
tissues  normal,  or  there  may  be  cirrhosis,  abscess 
or  gangrene. 

Diagnosis. — The  principal  points  in  the  diag- 
nosis are  the  sudden  onset,  single  initial  chill  with 
rapid  development  of  high  continued  fever,  rapid 
respiration  with  moderate  pulse,  facial  herpes, 
sticky  gray  sputa  soon  becoming  rusty,  crepitation 
in  first  stage  only,  then  dullness  limited  to  one  or 
more  lobes,  crisis  followed  by  rale  redux. 

In  acute  phthisis  the  onset  is  gradual,  with  re- 
peated chilliness,  remittent  or  intermittent  fever 
not  ending  in  crisis,  repeated  night-sweats,  no 
herpes,  rapid  loss  of  flesh,  bloody  purulent  sputa 
containing  elastic  tissue  and  tubercle  bacilli;  it 
begins  at  the  apex,  a  cavity  follows  consolidation, 
the  other  lung  is  invaded  in  time  and  tuberculosis 
follows  elsewhere. 

In  typhoid  fever  there  is  no  leucocytosis,  the 


104  THE   DISEASES    OF    THE   RESPIRATORY    ORGANS. 

typhoid  bacillus  is  to  be  found,  and  Widal's  test 
is  available;  a  drop  of  blood,  if  from  a  typhoid 
case,  added  to  a  pure  culture  of  the  typhoid  bacil- 
lus, stops  the  movements  of  the  bacilli  and  induces 
their  collection  into  clumps. 

In  children  meningitis  may  be  mistaken  for 
pneumonia ;  or  more  likely,  vice  versa.  Headache 
in  pneumonia  is  frontal,  in  meningitis  occipital, 
with  stiff  neck,  restlessness,  ugly  temper,  height- 
ened reflexes  and  hjrperesthesia,  low  variable  fever, 
no  crisis,  pulse  irregular. 

Prognosis. — Pneumonia  is  more  dangerous  to 
the  aged,  alcoholic,  debilitated  and  cachectic. 
Hemorrhagic  cases  are  dangerous.  Bad  symp- 
toms are  the  absence  of  leucocytosis,  prolonged 
high  temperature,  rapidity  and  weakness  of  the 
pulse,  early  active  delirium,  prune-juice  expectora- 
tion, implication  of  more  than  one  lobe,  and  the 
presence  of  complications.  Death  generally  oc- 
curs from  heart-failure,  due  to  overwork  and  sed- 
ation by  the  pneumotoxin.  Severe  collateral 
fluxion  is  a  condition  of  imminent  danger. 

Treatment. — The  treatment  of  pneumonia  has 
been  the  battle-ground  of  centuries.  Two  diamet- 
rically opposite  ideas  as  to  the  nature  of  the  danger 
have  led  to  the  antagonistic  principles  of  treatment 
by  sedation  and  by  stimulation.  The  ancient  clas- 
sical method  consisted  in  a  prompt  venesection, 
followed  by  leeches,  cups,  cathartics,  arterial  seda- 


PNEUMONIA.  105 

lives,  and  calomel  as  an  aplastic  agent,  with  blis- 
ters and  iodine  to  promote  absorption  following 
crisis.  The  modern  expression  of  this  theory  is 
found  in  the  administration  of  veratrum  viride  and 
aconitine,  acetanilid,  and  local  applications  of 
cold. 

The  reaction  against  the  antiphlogistic  practice 
led  to  the  stimulant  treatment,  which  has  been 
urged  with  matchless  force  by  Juergenson.  Basing 
his  argnement  on  the  mechanical  difficulties  of  the 
circulation,  he  shows  that  every  important  element 
increases  the  work  of  the  heart  or  subtracts  from 
its  power;  and  deduces  a  treatment  by  antipyretic 
doses  of  quinine,  red  wine,  raw  beef  and  cold  baths. 
Petrescu  gives  digitalis  by  hundreds  of  grains. 
Wood  relies  on  strychnine  and  cocaine,  others  on 
quinine,  Bourbon  whisky  and  other  supposed  stim- 
ulants. And  as  both  parties  support  their  theories 
by  long  lists  of  cases  treated,  with  a  notable  scar- 
city of  deaths,  others  drop  all  attempts  at  domi- 
nant therapeutics,  concluding  that  such  good  re- 
sults from  discordant  methods  argue  the  com- 
parative harmlessness  of  the  disease,  since, 
whichever  is  right,  the  patients  of  the  others  must 
recover  in  spite  of  the  treatment. 

But  pneumonia  is  not  a  notably  innocuous  mal- 
ady. Anders  gives  the  mortality  in  hospitals  as 
25  per  cent,  in  private  practice  15,  and  quotes 
Wells'  collection  of  223,730  cases  with  a  mortality 


106  THE   DISEASES    OF    THE    RESPIRATORY    ORGANS. 

of  18.1  per  cent.  Furthermore^  it  is  to  be  ob- 
served that  the  results  of  expectant  or  nihilistic 
treatinent  are  not  as  good  as  those  secured  by  the 
use  of  either  stimulants  or  sedatives. 

ISTevertheless,  these  contradictions  are  only  ap- 
parent, and  can  be  reconciled  by  considering  a  few 
points  in  the  pathology.  It  may  be  admitted  that, 
the  quantity  of  blood  in  the  body  remaining  the 
same,  an  excess  in  one  part  necessitates  a  deficiency 
in  another.  If  the  pulmonary  capillaries  are  ab- 
normally engorged,  other  capillaries  are  abnor- 
mally empty ;  or,  in  other  words,  if  there  is  paresis 
of  the  pulmonary  vasomotors,  there  is  spasm  of 
some  other  section  of  the  vasomotors.  Therefore, 
while  one  party  relaxed  the  spasmodic  contraction 
in  one  place  and  permitted  the  blood  to  flow  back 
out  of  the  hyperemic  area,  the  others  restored  the 
tonicity  of  the  paretic  pulmonary  capillaries  and 
forced  out  the  excess  of  blood.  Each  did  good, 
though  acting  on  different  parts  of  the  body,  for 
each  employed  methods  tending  to  restore  that 
state  of  circulatory  equilibrium  we  term  health. 

But  if  two  antagonistic  pathologic  conditions 
can  exist  in  the  human  body  at  the  same  time,  may 
we  not  act  on  both  at  once  ?  If  vasomotor  toners 
and  vasomotor  relaxants  are  administered  to- 
gether, will  there  be  an  exact  balancing  of  the 
effects  and  no  results  follow  ?  Or  will  each  reme- 
dial agent  be  taken  up  by  the  tissue  requiring  its 


PNEUMONIA. 


107 


aid  for  the  restoration  of  the  physiologic  balance, 
as  the  blood  brings  it  to  the  affected  part? 
Whether  the  site  of  the  action  be  actually  the  af- 
fected tissues  or  the  centers  of  the  nervous  system 
controlling  them,  is  not  material  to  the  question — 
it  is  but  restating  the  problem  in  other  terms. 

The  solution  rests  in  experiment,  not  in  argu- 
ment ;  and  the  following  formula  results :  Acon- 
itine  amorphous  half  a  milligram  (gr.  1-134); 
veratrine  the  same  dose,  and  digitalin  one  milli- 
gram (gr.  1-67),  given  together  every  quarter, 
half,  one  or  two  hours,  according  to  the  predom- 
inance of  the  acute  sthenic  symptoms ;  substitut- 
ing strychnine  arsenate  half  a  milligram  (gr. 
1-134)  for  the  veratrine  as  asthenic  conditions  are 
manifested.  Aconitine  relaxes  vasomotor  spasm ; 
so  does  veratrine,  and  loosens  the  excretory  ap- 
paratus; digitalin  restores  vasomotor  tonicity, 
supports  and  steadies  the  heart  and  checks  the 
dangerous  tendency  to  hemorrhage;  stychnine 
still  more  powerfully  does  this,  and  energizes  all 
the  vital  functions,  while  arsenic  improves  the 
nutrition  of  the  heart. 

This  method  of  treatment  has  been  put  to  the 
test  of  clinical  trial  by  thousands  of  physicians, 
not  those  leaders  whose  mastery  of  the  art  would 
carry  their  patients  through  with  almost  any 
method,  but  the  rank  and  file  of  the  profession,  in 
city  and  country  alike.     The  results  have  been  so 


108  THE    DISEASES    OF   THE    RESPIRATORY    ORGANS. 

satisfactory  that  I  feel  fully  warranted  in  claiming 
that  the  average  mortality  in  their  hands  is  mnch 
less  than  that  reported  by  Wells.  The  system  has 
the  requisite  flexibility,  as  it  is  suited  to  sthenic  and 
asthenic  forms  alike,  and  can  be  changed  from  one 
to  the  other  in  a  moment. 

The  dose  is  to  be  repeated  frequently  until  the 
effect  is  manifest,  the  pulse  and  fever  down,  the 
skin  moist,  the  patient  comfortable.  The  number 
of  abortive  cases  met  after  the  adoption  of  this 
method  is  remarkable— cases  the  physician  diag- 
noses as  pneumonia,  but  in  a  day  or  two  the  symp- 
toms subside,  so  that  he  is  at  a  loss  to  know  just 
what  has  been  the  malady  he  has  treated. 

While  this  is  the  dominant  treatment  of  pneu- 
monia, there  are  important  adjuncts.  Chief 
among  these  are  the  intestinal  antiseptics.  In  all 
fevers  there  is  a  suspension  of  the  secretion  of  bile, 
gastric,  pancreatic  and  intestinal  fluids,  the  nat- 
ural antiseptics  of  the  alimentary  canal.  Add  to 
this  the  increased  heat,  and  we  have  in  the  bowels 
an  ideal  place  for  the  unrestricted  activity  of 
micro-organisms,  their  multiplication  and  the  pro- 
duction of  toxins;  while  the  rapid  loss  of  fluids 
from  the  skin  favors  reabsorption  from  the  bowel. 
Consequently  we  have  in  every  fever  autotoxemia 
as  a  necessary  element,  and  a  certain  proportion 
of  the  symptoms  of  the  attack  may  be  credited  to 
that  element.    Numerous  observations  have  led  me 


PNEUMONIA.  109 

to  the  belief  that  from  twenty  to  fifty  per  cent  of 
the  symptoms  in  gross  are  due  to  this  autotoxemia, 
and  are  to  be  obviated  by  clearing  out  the  ali- 
mentary canal  and  rendering  it  aseptic.  For  this 
purpose  I  administer  a  few  doses  of  calomel,  gr. 
1-6  every  hour  for  six  doses,  with  saline  laxatives 
enough  to  empty  the  bowels  completely  and  keep 
them  open  thereafter.  Then  I  administer  zinc 
sulphocarbolate  two  to  four  decigrams  (gr.  iij-vj), 
every  two  to  four  hours  until  the  stools  are  odor- 
less, then  just  enough  to  keep  them  so.  There  will 
be  no  gastro-intestinal  complications. 

As  collateral  fluxion  is  one  of  the  most  serious 
conditions,  it  is  well  to  accept  the  fact  that  a  re- 
duction of  the  bulk  of  the  blood  gives  instant  relief. 
Imminent  danger  of  suffocation  demands  venesec- 
tion, prompt  and  free  enough  to  give  relief.  Even 
if  the  loss  of  blood  were  to  be  felt  severely  in  the 
later  stages,  the  urgency  of  the  present  over- 
weighs  that  consideration.  But  we  have  been  too 
much  under  the  influence  of  the  reaction  against 
blood-letting,  and  have  ignored  the  ease  with 
which  such  a  loss  is  recouped  by  the  body.  Cases 
are  exceptional  in  which  the  withdrawal  of  a  quart 
of  blood  is  seriously  felt  thereafter.  The  emer- 
gency may,  however,  be  in  some  measure  pre- 
vented by  reducing  the  bulk  of  the  food,  and  thus 
the  bulk  of  the  blood.  Let  the  food  be  highly 
concentrated  and  nutritious,  easily  digestible  or 


110  THE    DISEASES    OF    THE   RESPIRATORY    ORGANS. 

predigested;,  with  the  smallest  quantity  of  water. 
Thirst  may  be  relieved  by  chewing  gum,  or  by 
small  pellets  of  ice,  repeated  not  oftener  than 
every  half-honr.  If  left  to  himself  the  patient 
will  want  it  every  half -minute.  Eaw  white  of  egg, 
scraped  beef  or  grated  oysters,  and  the  beef  con- 
centrations, with  small  portions  of  junket  and 
fresh  fruit-juices,  constitute  the  best  diet. 

As  a  rule  I  prefer  hot  applications  to  the  chest 
rather  than  cold.  The  hot  mush- jacket,  paste  of 
mustard  and  hot  molasses,  hot  larded  flannels, 
^^slap-jacks,^'  etc.,  may  sound  crude  to  modern 
ears,  but  their  efficacy  is  believed  in  by  many  excel- 
lent practitioners,  and  they  are  invariably  declared 
to  be  a  comfort  by  the  patients.  When  hyper- 
pyrexia is  present  I  have  been  compelled  to  apply 
cold  cloths,  because  there  was  no  time  for  the 
action  of  antipyretics.  I  then  use  Anderson's 
m^ethod:  Wring  a  towel  out  of  ice- water,  apply 
it  to  the  chest,  or  better  to  the  abdomen,  and 
cover  with  dry  flannels.  In  one  minute  whip  off 
the  towel  and  replace  it  with  a  fresh  one.  Eepeat 
this  for  half  an  hour,  making  thirty  changes,  then 
cover  with  warm  flannels  and  leave  an  hour  and  a 
half,  when,  if  the  temperature  is  above  105°,  re- 
peat. I  have  kept  up  these  half -hour  applications 
of  cold  every  two  hours  for  five  days,  before  the 
fever  subsided  enough  to  allow  their  discontinu- 
ance.   The  application  is  designed  as  a  means  of 


PNEUMONIA.  Ill 

reducing  the  general  fever  rather  than  as  a  local 
remedy.  It  is  far  easier  than  the  usual  cold  bath 
and  fully  as  effective. 

As  the  failure  of  leucocytosis  coincides  with  the 
worst  prognosis,  it  is  an  interesting  question  if  we 
should  not  induce  leucocytosis  by  administering 
nuclein  solution.  The  dose  is  a  gram  and  one- 
third  each  twenty-four  hours  (m.  xx). 

This  constitutes  the  treatment  of  pneumonia  per 
se, — the  "dominant"  treatment.  Certain  symp- 
toms and  conditions  demand  the  application  of 
variant  remedies. 

The  temperature  of  the  sick  room  should  be 
kept  at  65,  higher  with  children,  and  the  patient 
must  keep  his  bed  as  long  as  fever  lasts.  Care 
must  be  taken  to  avoid  any  emotion  or  exertion 
capable  of  throwing  a  strain  on  the  heart.  One 
of  my  patients  got  out  of  bed,  walked  upstairs, 
and  fell  dead  at  the  top  step.    "Heart-failure  \" 

Like  many  doctors,  I  began  to  treat  pneumonia 
with  whisky,  gradually  using  less,  and  now  for 
many  years  I  have  used  none.  It  is  a  delusion, 
and  does  nothing  but  harm.  When  treating  a 
man  accustomed  to  its  daily  use,  I  do  not  entirely 
cut  off  the  supply,  for  obvious  reasons. 

The  heart  will  not  fail  if  the  fever  is  kept  down, 
the  blood  deprived  of  superfluous  water,  the  ali- 
mentary canal  asepticized,  and  the  nutrition  kept 
up.     But  the  matter  is  so  vital  as  to  justify  the 


112  THE   DISEASES    OF   THE    RESPIRATORY    ORGANS. 

routine  administration  of  digitalin  as  advised, 
with  strychnin  when  indicated,  to  prevent  cardiac 
debility.  The  method  of  small  and  frequent 
dosage  has  only  to  be  tried  to  convince  one  of  its 
great  superiority  to  Wood^s  method  of  giving 
strychnine  in  a  full  dose,  three  milligrams  (gr. 
1-20)  every  four  hours;  with  over-stimulus  as  a 
result  followed  by  depression,  which  is  by  no  means 
obviated  by  alternating  doses  of  cocaiii.  By  the 
dosage  recommended  a  minimum  dose  is  repeated 
at  short  intervals  until  the  experienced  finger  on 
the  pulse  shows  that  the  point  of  "dose  enough" 
has  been  reached,  and  then  enough  is  given  to 
exactly  keep  up  that  effect. 

Of  the  remedies  for  collapse  the  best  is  the  in- 
travenous or  subcutaneous  injection  of  normal  salt 
solution,  one  to  three  pints,  repeated  if  neces- 
sary. 

Respiratory  failure  may  be  met  by  adding 
atropine  sulphate  to  the  regular  medicine,  until 
the  pupil  begins  to  dilate,  the  skin  to  flush  or  the 
mouth  to  become  dry.  The  inhalation  of  oxygen 
is  indicated  by  cyanosis,  continued  and  repeated 
simply  as  needed,  without  regard  to  the  quantity 
used.  As  cyanosis  is  usually  due  to  collateral 
fluxion,  in  young  adults  venesection  is  the  remedy. 
But  in  the  aged  and  very  feeble  it  is  apt  to  be  due 
to  the  retention  of  secretions,  the  patient  "drown- 
ing in  his  own  sputa"  literally,  and  it  then  calls 


PNEUMONIA.  113 

for  sanguinarine  nitrate,  three  milligrams  (gr. 
1-20)  every  hour  till  relieved,  with  coffee  and 
strychnine  in  full  doses. 

Nothing  relieves  the  pleuritic  pain  so  com- 
pletely as  a  leech  or  cup,  applied  over  the  painful 
spot.    A  blister  is  a  poor  substitute. 

If  cerebral  symptoms  are  marked,  elimination 
by  the  kidneys  should  be  carefully  maintained, 
with  gelsemine,  one  milligram  (gr.  1-67)  added 
to  each  dose  of  the  regular  medicine,  and  ice  to  the 
head  if  required. 

Cough  may  require  codeine  and  emetine,  one  to 
five  milligrams  (gr.  1-67  to  1-12)  each  as  needed, 
but  is  best  relieved  by  inhalations  of  steam  to  soothe 
the  inflamed  tissues.  Counter-irritants  over  the 
course  of  the  pneumogastric  nerve  in  the  neck  are 
also  of  great  value.  After  the  crisis,  expectoration 
may  be  facilitated  by  emetin,  ammonium  iodide 
or  scillitine,  in  small  doses,  with  mildly  stimulant 
liniments  or  hot  salt  rubs  to  the  chest. 


CHAPTER  XXI. 
INFLUENZA. 

Although  this  ranks  as  an  epidemic,  com- 
municable fever,  its  attacks  are  so  frequently 
directed  against  the  lungs  that  its  consideration 
is  necessary  in  this  work.  Since  the  epidemic  of 
1889-90  it  has  been  endemic  in  America,  and  no 
year  since  has  been  free  from  its  prevalence  in 
some  parts  of  the  United  States. 

The  lesions  found  on  autopsy  are  those  of  the 
accompanying  maladies,  with  respiratory,  gastro- 
intestinal or  genito-urinary  catarrhs. 

Etiology. — The  cause  of  influenza  is  the  bacil- 
lus discovered  by  Pfeiffer.  Stained  with  carbol- 
fuchsin  it  is  of  a  dumb-bell  shape.  It  is  found  in 
the  sputa,  blood  and  tissues,  and  can  be  cultivated 
in  agar  but  not  in  gelatin.  The  cultures  become 
larger  if  inoculated  with  staphylococcus  aureus. 
It  is  communicated  by  contagion,  is  carried  by  the 
air  or  on  clothes,  and  evidence  is  not  wanting  to 
show  that  it  is  carried  from  city  to  city  by  per- 
sons. Outbreaks  have  followed  the  receipt  of  let- 
ters written  by  members  of  a  family  where  the 
disease  prevailed.  The  bacilli  enter  the  body  by 
the  respiratory  mucosa,  probably  by  the  conjunc- 
tiva, possibly  by  the  alimentary  tract. 


INFLUENZA.  115 

As  predisposing  causes  we  may  name  age  (the 
malady  being  most  common  between  20  and  30, 
and  in  old  age),  debility,  chronic  diseases,  alcohol- 
ism, and  exposure  to  the  causes  of  catching  cold. 
One  attack  leaves  an  increased  liability  to  subse- 
quent seizures,  with  no  known  limit.  Anders  be- 
lieves that  malaria  subsides  during  epidemics  of 
influenza,  while  pneumonia  and  possibly  typhoid 
fever  increase.  Observations  at  our  laboratory 
show  that  the  influenza  bacillus  is  often  found  in 
the  sputa  with  numerous  other  micro-organisms. 

Symptoms. — The  incubation  is  short,  lasting 
from  a  few  hours  to  three  days.  The  onset  is  often 
sudden  and  violent,  with  chills,  fever  rushing  up 
to  105°  or  higher,  intense  pain  in  the  head,  back  or 
anywhere  else,  aching  muscles  and  great  prostra- 
tion. Delirium,  insomnia,  vomiting,  violent 
cough,  or  almost  any  group  of  symptoms  of  any 
local  disease,  may  be  present.  The  fever  may  be 
absent,  slight  or  hyperpyretic.  Vertigo,  apoplexy, 
eye-pain,  epistaxis,  shoulder-pain,  lumbago,  hyper- 
esthesia of  the  skin  or  mucosa,  dyspnea,  cyanosis, 
sweating  and  numerous  other  manifestations 
have  been  noted.  The  pulse  is  ataxic,  rapid,  weak, 
with  the  fever  falling  profoundly  under  moderate 
doses  of  antipyretics. 

In  the  respiratory  type  we  have  the  symptoms  of 
acute  catarrh  of  the  nose,  eyes,  throat,  larynx, 
bronchi  and  air-vesicles,  on  any  of  which  locations 


116  THE   DISEASES    OF   THE    RESPIRATORY    ORGANS. 

the  intensity  may  center.  The  cough  is  distress- 
ing, with  much  dyspnea.  Pneumonia,  lobar  or 
catarrhal,  frequently  coexists. 

Gastro-intestinal,  cardiac,  typhoid,  rheumatoid, 
neuralgic,  and  other  mixed  types,  have  been  de- 
scribed. The  malady  sometimes  but  not  always 
seizes  on  the  weak  or  diseased  portions  of  the  vic- 
tim's anatomy.  As  the  fever  declines  the  pros- 
tration becomes  more  apparent.  Pulmonary  edema 
may  occur  in  any  form  of  the  malady,  usually 
traceable  to  exposure.  Anders  thinks  it  dependent 
on  the  profound  prostration  of  the  nervous  system, 
which  also  annuls  largely  the  phagocytic  action  of 
the  leucocytes.  Lobar  pneumonia  may  occur  at  any 
stage,  especially  during  convalescence,  with  the 
usual  symptoms,  rapidly  progressing.  The  bron- 
chial and  other  glands  may  become  swollen  and  in- 
flamed. I  have  seen  great  numbers  of  the  super- 
ficial glands  inflamed,  with  an  erythematous 
eruption,  the  blood  presenting  Pfeiffer's  bacilli. 

Pleurisy,  pulmonary  gangrene  or  abscess,  car- 
diac disease,  pericarditis,  neuroses,  gastro-enter- 
itis,  meningitis,  neuritis  and  genito-urinary 
maladies,  acompany  influenza  occasionally.  A 
liability  to  tuberculosis,  and  other  maladies  that 
stand  ready  to  attack  men  in  moments  of  weak- 
ness, remain  after  the  subsidence  of  influenza. 

The  diagnosis  is  made  by  the  prevalence  of  the 
disease,  the  sudden  and  violent  attack,  the  intens- 


INFLUENZA.  117 

ity  of  the  suffering,  the  ataxic  condition  and  the 
profound  depresion  of  the  mental  and  physical 
forces.  Confirmation  is  secured  by  finding  the 
bacillus  of  Pfeiffer  in  acute  conditions,  but  after 
the  attack  is  over  this  micro-organism  may  be 
found  in  the  sputa  for  an  undetermined  period, 
possibly  for  years. 

The  prognosis  depends  largely  on  the  previous 
condition  of  the  patient  and  on  the  complications. 
Few  die  of  influenza  alone,  but  the  death-rate  is 
vastly  increased  by  it,  the  epidemic  carrying  off 
many  sufferers  from  chronic  maladies  of  the 
lungs,  heart,  kidneys,  bowels,  diabetics,  the  aged, 
etc. ;  while  the  number  of  deaths  from  pneumonia, 
typhoid  and  the  eruptive  fevers,  and  the  ordinary 
list  of  prevalent  affections,  is  largely  increased. 
But  as  the  weakly  are  thus  weeded  out,  the  years 
following  an  influenzal  epidemic  are  apt  to  show 
a  phenomenally  small  death-rate — unless  influ- 
enza remains  as  an  endemic. 

The  attack  lasts  from  two  days  to  many  weeks. 

Treatment. — Influenza  may  be  avoided  in  the 
case  of  delicate  persons  by  sending  them  to  out- 
of-the-way,  isolated  places,  where  there  is  little  or 
no  communication  with  infected  localities.  Those 
who  remain  during  epidemics  should  take  pains 
to  keep  up  the  health  and  strength,  avoid  catching 
colds  and  places  where  infected  persons  congre- 
gate, churches,  theaters,  street-cars,   department 


118 


THE  DISEASES   OF  THE   RESPIRATORY    ORGANS. 


stores,  etc.  "Wearing  a  respirator  impregnated 
with  antiseptics  would  be  of  value  if  one  cared  to 
take  the  trouble,  but  a  better  expedient  is  to  wash 
out  the  eyes,  nostrils,  mouth  and  throat  with  mild 
aromatic  antiseptics,  and  spray  with  a  mixture  of 
europhen  in  fluid  petrolatum,  one  part  to  twelve. 
This  leaves  a  bland  protective  over  the  most  ex- 
posed and  vulnerable  surfaces,  and  as  it  can  be 


INFLUENZA. 

ORDINARY     CATARRH. 

Exposure  to  contagion. 
Violent   onset. 

Exposure  to  cold  and  wet. 
Onset  mild  with  rigors. 

Excessive    pain. 

Great   depression. 

High     fever,     dropping     sud- 
denly before  antipyretics. 

Nervous    phenomena    promi- 
nent and  violent. 

Rapid  extension  of  catarrhs. 

Little  pain. 
Some  depression. 
Little  fever. 

Nervous    phenomena   inconsid- 
erable. 
Slow  extension. 

No   eruption. 

Muscle   pains    acute. 

Neuralgias  acute. 

Protean  and  irregular. 

Influenza  bacilli. 

applied  harmlessly,  may  be  used  several  times  a 
day.  The  use  of  alcohol  only  renders  the  user 
more  liable  to  the  attack  of  influenza,  as  it  relaxes 
vascular  tension  and  paralyzes  the  resistant  forces. 
The  student  of  epidemiology  will  note  that  the 
treatment  of  influenza  shows  the  following  char- 
acteristic history:  At  the  beginning  of  each  epi- 
demic the  treatment  proves  useless.     Near  the 


INFLUENZA.  119 

close  some  remedy  appears  to  be  efficacious  and 
acquires  a  reputation.  When  the  next  epidemic 
recurs  the  remedy  apparently  successful  in  the  last 
one  proves  useless,  but  towards  the  close  some 
other  becomes  popular,  only  to  be  found  worthless 
in  turn.  Since  we  know  that  all  epidemic  diseases 
exhibit  the  greatest  virulence  in  the  early  part  of 
the  visitation,  and  become  progressively  milder 
towards  its  close,  the  explanation  of  these  obser- 
vations is  easy.  Camphor,  quinine,  ammonia  and 
the  coal-tars  have  thus  won  and  lost  reputations. 
So  far  we  may  say  confidently  that  no  remedy  has 
as  yet  been  shown  to  exert  any  direct  or  specific 
control  over  the  course  and  termination  of  influ- 
enza. 

Nevertheless  it  seems  probable  that  the  true 
remedy  may  be  found  in  time,  and  it  is  one^s  duty 
to  take  up  and  put  to  the  test  any  theory  that 
contains  a  possibility  of  truth.  If  influenza  para- 
lyzes the  phagocytes,  give  nuclein,  hypodermically, 
in  rising  doses  till  it  shows  its  value  or  uselessness. 
If  the  sulphides  really  combat  all  living  infectious 
micro-organisms  in  the  body,  give  calcium  sul- 
phide, a  grain  seven  times  a  day  till  the  breath  ex- 
hales the  drug^s  odor,  and  note  the  effect.  If,  as 
Sir  Benjamin  Ward  Richardson  asserted,  the  true 
remedy  must  be  one  that  antagonizes  the  profound 
paralysis  of  tension,  we  must  look  for  it  among 
the  vasomotor  tensors  of  the  strychnine  group.   It 


120 


THE   DISEASES  OF   THE    RESPIRATORY    ORGANS. 


has  been  assumed  that  the  virtues  of  these  are  rep- 
resented by  strychnine  alone,  but  this  is  unproved 
and  improbable.  Brucine,  thebaine,  laudanine, 
and  the  other  tetanisant  alkaloids,  may  and  proba- 
bly have  variations  in  their  effects,  that  will  yet  be 
utilized  in  the  treatment  of  disease.  I  have  ob- 
tained excellent  results  from  thebain  in  a  case  of 
paraplegia,  where  strychnin  could  not  be  borne 


INFLUENZA. 

HAY    FEVER. 

RHINITIS. 

Occurs  during  epi- 
demic. 

Recurs     at      same 
season. 

Occurs  at  any- 
time. 

Duration        indefi- 
nite. 

Persists   till   frost. 

Can  be  aborted 
or  run  regular 
course. 

Produced  by  smell- 
ing causal  flower. 

Not  affected  by 
any  plant. 

Onset  sudden. 

Sudden  onset. 

Onset  less  abrupt. 

No  diathesis. 

Neurotic  diathesis. 

Catarrhal  habit. 

Great    prostration. 

Intense    suffering. 
Muscular  pains. 

Protean      manifes- 
tations. 

Influenza   bacilli. 

in  any  dose  capable  of  beneficial  action. 

Whichever  is  employed  it  should  be  given  in 
small  and  frequent  doses  until  the  normal  tonicity 
is  obtained,  and  then  often  enough  to  sustain  this 
effect.  Brucin,  half  to  one  milligram  (gr.  1-134 
to  1-67)  every  half -hour,  would  be  my  present 
choice,  the  doses  increased  if  the  debility  indicated 
it.  Gigantic  doses  may  be  needed — a  centigram 
(gr.  1-6)  every  two  hours. 


INFLUENZA.  121 

The  mildest  cases  require  this  tonic  medication, 
and  it  should  not  be  neglected  during  convales- 
cence, as  relapses  and  sequels  are  common  and 
dangerous. 

Pain  may  be  relieved  by  heat  or  cold,  by  small 
and  frequent  doses  of  acetanilid  or  camphor  mono- 
bromid,  a  decigram  (gr.  IJ)  each,  and  half  this 
dose  of  caffein,  every  half  to  two  hours.  Chloro- 
form liniment,  camphor  chloral  and  belladonna 
plaster,  are  useful  locally.  Cannabis  Indica  in 
doses  of  a  centigram  (gr.  1-6)  of  a  good  extract, 
sometimes  gives  great  relief,  especially  when  there 
are  gastro-intestinal  pains. 

Fever  is  best  relieved  by  the  combination  of 
aconitine,  digitaline  and  strychnine  arsenate,  fre- 
quently advised  in  this  work.  If  the  coal-tars  are 
employed  they  should  only  be  given  in  small  doses, 
with  zinc  or  caffeine  valerianate,  which  are  inval- 
uable in  all  ataxic  febrile  states. 

For  the  cough  I  prefer  inhalations  of  europhen 
with  petrolatum  spray,  and  rarely  small  doses  of 
codeine,  half  a  centigram  (gr.  1-12),  but  for  the 
irritative  laryngeal  cough  of  convalescence  the  best 
remedy  is  yerba  santa,  given  ad  libitum,  for  effect. 
Counter-irritation  over  the  right  pneumogastric 
nerve  in  the  neck  usually  moderates  the  cough. 

Complications  and  sequels  require  their  own 
treatment,  the  tendency  to  debility  and  collapse 
being  ever  borne  in  mind. 


122  THE  DISEASES   OF  THE   RESPIRATORY   ORGANS. 

The  diet  from  the  first  should  be  highly  digesti- 
ble and  nutritious,  given  in  small  doses  at  fre- 
quent intervals,  with  digestants.  It  is  best  to 
give  food  every  four  hours,  with  an  intervening 
glass  of  liquid  nutriment.  Eggs,  underdone  beef, 
fish,  oysters,  chicken,  turkey,  lamb,  venison,  quail, 
squab,  squirrel  or  rabbit  broiled,  roasted  or  stewed ; 
stewed  terrapin  or  turtle,  with  rice  and  similar 
f arinacea,  are  well  suited  for  the  four-hour  meals ; 
while  at  the  two-hour  intervals  may  be  given  a 
bowl  of  clam  or  other  broth,  cold  consomme,  jun- 
ket, custard,  freshly  pressed  fruit-juices,  raw 
egg,  coffee,  tea,  chocolate  or  cocoa  (made  with 
milk  instead  of  water),  are  advisable.  A  dose  of 
one  of  the  papaw  derivatives,  or  of  acid  and  pep- 
sin, or  diastase,  is  usually  required  at  each  feeding. 

The  patient  must  be  kept  in  bed  as  long  as  he 
has  fever  or  pain,  and  in  his  room  as  long  as  the 
heart  is  markedly  weak.  The  room  must,  how- 
ever, be  thoroughly  and  constantly  ventilated. 
Hot  salt  baths,  vinegar  sponging  if  there  is  profuse 
sweating,  massage  of  sore  muscles  and  joints  with 
hot  oil,  and  the  other  means  of  keeping  up  the 
strength,  are  required. 

I  have  not  been  able  to  satisfy  myself  that  qui- 
nine is  of  any  use  in  influenza.  I  have  never 
known  alcohol  do  aught  but  harm.  It  is  formally 
contradicted  by  the  relaxed  vascular  tension. 


CHAPTER  XXII 

ACUTE  PHTHISIS 

Etiology. — In  1881  Robert  Koch  discovered  the 
true  cause  of  the  disease,  the  tubercle  bacillus. 
This  discovery  was  foretold  by  Niemeyer,  who 
described  clearly  the  symptoms  and  lesions  of 
phthisis  before  and  after  the  advent  of  the  bacil- 
lar  invasion.  His  views  have  been  verified  by 
the  observations  made  in  my  twenty-five  years' 
clinical  studies;  and  though  at  present  not  held 
by  the  leading  teachers,  I  expect  to  see  them 
confirmed  before  many  years,  and  to  see  the  pro- 
fession swing  back  to  the  level  of  his  teachings. 
At  present  the  bacillus  has  carried  the  pendulum 
too  far  to  one  side. 

I  have  indulged  in  a  little  prediction  myself; 
and,  as  I  claimed  over  ten  years  ago,  it  has  been 
found  that  the  tubercle  bacillus  does  not  monop- 
olize the  destruction  of  the  human  lung.  In  exam- 
ining sputa  at  the  laboratory  we  find  tubercle 
bacilli,  pneumococci,  influenza  bacilli,  strepto-, 
etaphylo-,  and  gonococci,  and  sometimes  typhoid 
bacilli,  variously  combined.  Until  we  are  able  to 
differentiate  the  effects  of  these  organisms  we  must 
treat  of  phthisis  as  a  simply  tubercular  or  as  a 
mixed  infection. 


124  THE   DISEASES   OF   THE   RESPIRATORY   ORGANS. 

Phthisis  prevails  in  every  inhabited  country  of 
the  globe^  from  the  poles  to  the  equator.  It  is 
most  prevalent  when  the  population  is  crowded, 
poor  and  dirty;  less  frequent  as  we  approach  the 
poles  or  ascend  above  the  sea-level,  for  the  simple 
reason  that  population  there  becomes  sparser. 
Statistics  showing  a  less  prevalence  of  this  malady 
at  5,000  feet  above  the  sea-level,  and  almost  a 
total  absence  of  it  at  10,000  feet  elevation,  must 
be  read  with  the  knowledge  that  the  vast  bulk 
of  the  world's  inhabitants  live  less  than  5,000 
feet  above  sea-level,  and  very  few  above  10,000 
feet.  If  among  the  few  scattered  thousands,  out 
of  a  billion  and  a  half,  there  are  still  some  tuber- 
culous individuals,  it  speaks  strongly  for  the  uni- 
versality of  this  dreaded  microbe.  There  are 
reasons,  however,  for  some  degree  of  immunity  in 
mountaineers.  The  thin  air  causes  unusual  devel- 
opment of  the  lungs,  as  their  swelling  chests  tes- 
tify; the  pure  air  is  free  from  bacteria,  and  the 
sparse  population  renders .  successive  infections 
unlikely.  The  outdoor  life,  the  rude  exercise,  the 
absence  of  city  dissipations,  conduce  to  health 
in  those  not  killed  off  by  the  privations. 

Pathology. — The  entrance  of  the  tubercle  bacil- 
lus into  lung-tissue  is  followed  by  proliferation  of 
the  connective  tissue  and  epithelium,  formation  of 
giant  cells  and  influx  of  leucocytes,  both  possibly 
for  phagocytic  defense,     A  netting  of  connective 


ACUTE   PHTHISIS.  125 

tissue  surrounds  the  tubercle  and  shuts  it  off  more 
or  less  effectually  from  the  surrounding  tissues. 
The  tubercle  undergoes  either  caseation  or  scler- 
osis. In  the  former  case  the  cells  become  yellow- 
ish, amorphous,  growing  at  the  margins  till  they 
unite  in  masses.  These  either  soften  and  break 
down  into  cavities,  or  are  encapsulated,  the  cheesy 
contents  becoming  chalky,  the  tubercular  process 
extinct. 

In  sclerosis  the  hyaline  transformation  of  the 
mass  occurs  with  the  formation  of  fibrous  tissue, 
the  process  extending  into  the  surrounding  pul- 
monary structures.  Contraction  follows  as  in 
other  cirrhotic  affections.  Caseation  and  sclerosis 
often  coexist.  Calcification  and  sclerosis  are  evi- 
dences of  cure,  of  the  body's  success  in  the  battle 
with  the  invading  bacilli.  If  the  invaders  are 
few  and  the  body  well-supplied  with  the  phagocytic 
leucocytes,  producing  the  defensive  proteids  in 
abundance,  the  victory  goes  to  the  defense.  The 
processes  may  be  confined  to  one  or  a  few  points, 
or  may  involve  a  lobe,  a  lung,  or  both  lungs. 

Surrounding  the  tubercle  is  a  zone  of  inflamma- 
tion caused  by  it,  in  which  fibrosis  occurs.  Into 
this  the  bacilli  may  penetrate,  extending  the  dis- 
ease process,  or  it  may  become  circumscribed, 
checked  or  even  extinguished.  Sometimes  the  first 
focus  is  thus  cut  off,  and  in  it  the  bacilli  remain, 
quiet  but  alive,  until  at  some  time,  perhaps  after 


126         THE  DISEASES   OF  THS   RESPIRATORY   ORGANS. 

years,  circumstances  allow  their  egress  into  the 
lung  or  other  parts  of  the  body  and  the  fight  is 
resumed.  Various  bacteria  unite  in  the  struggle, 
causing  destruction  of  lung-tissue,  iever,  hectic, 
sepsis,  etc. 

Koch's  bacillus  is  a  curved  rod,  in  length  one- 
third  to  one-half  the  diameter  of  a  red  blood- 
corpuscle,  the  ends  rounded,  non-motile,  with 
spots  representing  vacuoles.  Stained  bacilli  have 
a  beady  appearance.  They  are  best  grown  in 
blood-serum,  at  a  temperature  between  98°  and 
100°.  Heat  the  serum  till  coagulated;  on  cooling 
rub  on  it  the  cut  surface  of  a  bit  of  tuberculosis  tis- 
sue, leaving  it  on  the  surface.  In  two  weeks  appear 
colonies  of  dry  grayish  scales.  If  with  these 
iguinea-pigs  are  inoculated  tubercles  appear  in 
about  three  weeks.  From  cultures  an  albuminoid 
substance  has  been  extracted,  which  causes  fever 
when  injected  into  the  body.  It  is  a  nuclear  pro- 
teid,  not  a  toxin.  A  ptomain  and  extract  have 
also  been  separated.  Part  of  the  symptoms  are 
due  to  the  production  of  these  toxins.  Outside  of 
the  body  the  bacilli  live  an  unknov/n  period,  with- 
standing extreme  cold,  water  or  dryness,  but  killed 
by  a  few  minutes'  boiling  or  by  exposure  to  the 
sun's  rays.  They  are  believed  to  be  incapable  of 
reproduction  except  in  an  animal  body. 

The  liability  to  tuberculosis  is  great  in  those 
who  change  from  an  open  air  to  house-habitation. 


ACUTE   PHTHISIS.  127 

The  Indians  who  leave  their  tepees  for  houses  die 
off  rapidly  of  tuberculosis. 

Varieties. — Acute  phthisis  may  be  either  tuber- 
cular or  non- tubercular.  Of  the  latter  form  the 
following  case  may  serve  as  an  example:  The 
Buperintendent  of  a  cemetery,  a  young  man  of 
slender  build  but  healthy  in  person  and  habits. 
The  body  of  a  woman  dead  of  "consumption"  had 
been  placed  in  a  vault.  When  the  vault  was 
opened  it  was  found  that  the  body,  which  had 
been  enormously  swollen  at  death,  had  burst  and 
the  fluids  had  covered  the  floor  of  the  vault.  The 
stench  was  so  great  that  the  employees,  men  ac- 
customed to  such  work,  refused  to  enter  the  vault. 
Carbolic  acid  in  large  quantities  was  thrown  in, 
and  the  superintendent  to  set  an  example  entered 
first,  and  remained  for  some  time  until  the  clean- 
ing was  done.  He  was  seized  with  shivering,  fol- 
lowed by  high  fever,  violent  cough,  the  sputa 
remaining  liquid  after  48  hours  from  the  time 
they  were  ejected.  The  temperature  was  105°  and 
over,  night-sweats  came  on,  with  rapid  failure  of 
strength,  and  emaciation,  but  a  remarkable  ab- 
sence of  the  comitant  symptoms,  as  the  man 
scarcely  kept  his  bed.  The  sputa  was  thin,  copi- 
ous, serous,  and  pronounced  by  the  bacteriologist 
to  consist  of  a  pure-culture  of  "bacterium  termo,'' 
there  being  no  tubercle  bacilli.     For  several  days 


128  THE  DISEASES   OF  THE  RESPIRATORY   ORGANS. 

the  patient  exhaled  the  odor  of  carbolic  acid  and 
the  urine  became  dark. 

He  improved  somewhat  and  was  sent  to  San 
Antonio,  Texas,  where  he  resided  for  some  years, 
recovering  entirely,  according  to  his  own  report 
ten  years  later. 

In  1869  a  man  was  brought  into  the  clinic  at 
Charity  Hospital,  Cleveland,  with  the  diagnosis  of 
acute  phthisis.  This  was  questioned  by  that  fine 
diagnostician.  Prof.  Scott,  on  the  ground  of  insuf- 
ficient evidence.  The  only  symptoms  were  fever 
of  104°,  rapid  respiration,  slight  cough,  and  a  sen- 
sation of  oppression  in  the  chest,  with  just  enough 
gastro-intestinal  irritation  to  arouse  the  suspicion 
of  typhoid  fever.  The  patient  died  in  four  days, 
and  at  the  autopsy  his  lungs  were  literally  stuffed 
with  miliary  tubercles,  in  phenomenal  numbers, 
there  being  not  a  spot  where  a  pencil-point  could 
be  put  that  was  free.  Prof.  Scott  dwelt  on  the 
fact  that  there  had  been  no  dullness  on  percus- 
sion. 

Four  robust,  healthy  Irishmen,  engaged  in  the 
particularly  healthful  occupation  of  peddling  coal 
about  the  streets  of  the  city,  slept  in  a  room  so 
small  that  their  two  beds  and  a  wash-stand  filled 
all  but  just  enough  room  to  open  the  door,  so 
that  they  had  to  climb  into  bed  over  the  foot- 
board. One  contracted  tuberculosis,  and  lived 
about  three  months.    The  second  to  be  attacked 


ACUTE   PHTHISIS.  129 

was  likewise  affected,  and  died  in  six  weeks.  The 
third  was  seized  while  these  two  were  still  occu- 
pying the  room,  and  he  died  in  four  days.  The 
autopsy  showed  a  condition  of  the  lungs  closely 
similar  to  that  of  Dr.  Scott's  patient  as  detailed 
above.  Here  we  have  all  the  conditions  necessary 
for  the  most  virulent  infection,  these  illiterate 
men  being  confined  in  a  very  small  room,  with 
no  ventilation,  spitting  on  the  walls  and  bedding 
until  the  air  was  fairly  saturated  with  the  bacilli. 

Several  cases  of  acute  tubercular  phthisis  came 
under  my  observation  in  a  paper-box  factory. 
Many  girls  worked  closely  crowded  in  one  room, 
the  windows  usually  closed  because  the  drafts  in- 
terfered with  the  gas-jets  employed  to  keep  the 
glue-pots  warm.  Some  among  these  girls  were 
always  consumptive,  and  the  contagion  was  thus 
transmitted  in  concentrated  form.  The  course 
was  from  six  to  twelve  weeks. 

Symptoms. — The  onset  is  sometimes  marked  by 
a  chill  resembling  that  of  pneumonia,  or  by  a 
period  of  depressed  health,  with  dyspnea,  bronchial 
hemorrhage,  hard  dry  cough,  fever  running  very 
high,  rapid  wasting,  hurried  breathing,  anorexia, 
constipation,  night-sweats,  and  inability  to  breathe 
comfortably  while  lying  down.  The  face  has  a 
curious  smoky  look  sometimes,  or  there  may  be 
cyanosis.  As  the  malady  advances  there  are  syrap- 
toms   of  general    broncho-pneumonia,    crepitus, 


130  THE  DISEASES  OF  THE  RESPIRATORY   ORGANS. 

slight  dullness  or  increased  resonance,  the  patient 
complaining  of  a  stuffy  sensation  in  the  chest. 
The  pulse  is  rapid  and  weak.  The  fever  in  very 
acute  cases  is  apt  to  exceed  105°  F.  Epistaxis 
sometimes  occurs.  Debility  and  wasting  progress 
rapidly.  Delirium  and  other  nervous  phenomena 
depend  on  the  fever  present. 

The  diagnosis  is  often  difficult,  but  the  hurry 
of  respiration,  rapid  development  of  the  fever  and 
its  height,  cyanosis  and  other  evidences  of  pulmon- 
ary involvement,  without  physical  signs  of  pneu- 
monia or  the  abdominal  symptoms  of  typhoid 
fever,  usually  indicate  the  malady,  which  is  con- 
firmed by  the  presence  of  numerous  tubercle  bacilli 
in  the  sputa.  Examination  of  the  blood  shows 
leucocytosis  only  if  suppuration  is  going  on.  Tu- 
bercles may  be  detected  in  the  choroid. 

In  less  acute  cases  the  examination  of  the  sputa 
for  bacilli  may  be  the  only  means  of  surely  diag- 
nosing the  tubercular  affection  from  various  pul- 
monary inflammations.  A  whole  single  lobe  may 
be  involved  in  the  tubercular  affection,  the  course 
simulating  that  of  pneumonia  with  missed  crisis. 
Bronchial  hemorrhages  more  frequently  are  fol- 
lowed by  subacute  than  by  hyperacute  attacks. 
The  sputa  is  usually  thin  and  serous,  and  if  ejected 
upon  a  handkerchief  remains  liquid  instead  of 
drying  up.  If  bronchial  hemorrhage  occurs  the 
sputa  thereafter  contains  blood  or  its  debris,  with 


ACUTE    PHTHISIS.  131 

the  mucus  and  pus  supplied  by  the  consequent 
inflamir.ation.  The  physical  signs  are  those  due  to 
consolidation  of  the  lung-tissues,  and  the  presence 
of  secretion,  varying  with  its  quantity,  consis- 
tency and  location.  Death  usually  occurs  before 
there  has  been  time  for  consolidation  or  cavity 
formation.  As  usual  in  tuberculosis,  the  patient 
is  hopeful  to  the  last.  If  the  case  is  prolonged 
till  a  cavity  has  formed  the  sputa  contain  elastic 
fibers  from  the  disintegrating  lung-tissues.  Hem- 
optysis may  occur  towards  the  last  from  erosion 
of  an  artery,  and  may  be  fatal. 

Prognosis. — The  prognosis  is  bad  if  the  lung 
is  universally  affected,  the  sputa  swarming  with 
tubercle  bacilli  or  streptococci,  the  course  rapid, 
the  fever  persistently  high,  and  if  hemorrhage 
from  erosion  occurs.  Niemeyer  did  not  consider 
non-tubercular  "galloping  consumption''  neces- 
sarily fatal,  and  McCall  Anderson  reported  cures. 
My  two  cases  of  non-tubercular  broncho-pulmon- 
ary mycosis  recovered. 

Treatment.. — It  is  of  the  utmost  importance  to 
subdue  the  inflammation  before  it  has  disorgan- 
ized the  pulmonary  parenchyma.  For  this  purpose 
an  effective  method  is  the  application  of  ice-cloths 
to  the  abdomen,  changing  every  minute  for  half  an 
hour,  and  repeating  every  two  hours  while  the 
fever  is  above  103°.  Internally  the  most  satis- 
factory antithermic  is  a  combination  of  guaiacol 


133  THE  DISEASES   OF  THE  RESPIRATORY   ORGANS. 

and  piper azin^  two  to  three  decigrams  (gr.  iij  to  v) 
each  every  four  hours.  Half  a  gram  (gr.  vijss) 
of  guaiacol  rubbed  into  the  skin  over  the  lung  has 
also  shown  an  efficacy  that  is  remarkable,  as  this 
agent  is  not  antipyretic  when  given  internally 
alone,  except  as  an  intestinal  antiseptic.  For 
slighter  fever  the  oft-recommended  combination 
of  aconitine,  digitaline  and  strychnine  arsenate  is 
most  useful.  The  bowels  must  be  kept  free  by  the 
use  of  mild,  non-depressant  saline  laxatives,  and 
aseptic  by  calcium  sulphocarbolate,  two  to  four 
grams  daily  (gr.  xxx  to  Ix).  Decided  comfort 
sometimes  follows  the  application  of  a  mush- jacket 
to  the  chest.  Night-sweats  are  restrained  by  atro- 
pine or  agaricine  until  the  antipyretic  measures 
have  had  time  to  act.  The  diet  should  be  highly 
nourishing,  easily  digestible,  and  free  use  made  of 
the  artificial  digestants,  Caroid,  diastase  and  acid- 
pepsin.  Milk,  eggs,  oysters,  beef,  game,  terrapin 
or  turtle,  fruit-juices,  and  the  concentrated  albu- 
minoids popularized  in  recent  years,  are  the  best 
foods;  though  it  must  not  be  forgotten  that  per- 
sons differ  as  to  their  digestive  capacity  and  tastes, 
and  that  each  will  do  best  on  what  he  likes  best. 
Beyond  this  the  treatment  is  symptomatic. 

Calcium  sulphide  has  been  recommended  as  a 
direct  antagonist  to  bacteria,  and  for  'its  un- 
doubted power  of  checking  suppuration.  It  should 
be  given  in  full  doses,  half  a  gram  (gr.  vijss) 


ACUTE    PHTHISIS.  133 

daily  of  the  pure  salt,  continued  until  the  odor 
of  the  breath  and  skin  show  the  body  to  be  satur- 
ated with  the  drug,  and  then  in  smaller  doses  to 
keep  up  this  effect. 

The  production  of  leucocytosis  by  the  adminis- 
tration of  nuclein  has  been  also  advised.  Those 
who  have  reported  the  best  results  from  it  gave 
it  in  very  large  doses,  four  to  six  grams  (gr.  Ix  to 
xc)  daily  by  the  skin  or  mouth.  The  idea  is  too 
important  to  be  allowed  to  go  by  default,  and 
should  be  tested  thoroughly.  Too  many  remedies 
have  been  introduced  and  allowed  to  fall  into 
oblivion  without  a  true  trial. 

Whether  sprays  or  vapors  ever  reach  the  seat 
of  the  disease  or  not,  they  are  useful  in  relieving 
the  cough  and  cleansing  the  pulmonary  tract  of 
secretions.  Let  the  patient  steam  the  lungs  by 
inhaling  the  fumes  of  boiling  vinegar  for  ten  min- 
utes, and  then  spray  with  menthol  camphor  in 
albolene,  or  europhen  in  fluid  petrolatum.  This 
soothes  the  irritated  tissues,  and  usually  permits  a 
good  night's  sleep,  undisturbed  by  coughing. 

The  sickroom  must  be  constantly  disinfected  by 
the  vaporization  of  volatile  oils,  eucalyptol  or 
cinnamon,  and  by  thorough  ventilation.  So  im- 
pori;ant  is  this  that  it  is  a  question  whether  the 
injury  to  the  patient  resulting  from  the  re-inhala- 
tion of  the  floating  bacilli  is  not  more  dangerous 
than  any  possible  exposure  to  the  outside  air. 


134  THE   DISEASES   OF   THE   RESPIRATORY    ORGANS. 

Some  corLsnmptives  bear  the  fumes  of  burning 
sulphur  in  an  astonishing  manner,  and  tlien  this 
method  of  purifying  the  air  is  to  be  preferred. 
But  while  there  is  fever  the  patient  should  be  in 
bed,  and  climato-therapy  applies  rather  to  the 
chronic  forms  of  the  malady. 


PART  II. 
CHRONIC  RESPIRATORY  DISEASES. 


CHAPTER  XXIII. 

CHRONIC  BRONCHITIS. 

Under  this  term  are  grouped  a  number  of  affec- 
tions differing  as  to  their  causes  and  as  to  their 
pathologic  conditions.  The  mucous  membrane 
may  be  denuded  of  its  epithelium,  thin,  the 
longitudinal  elastic  fibers  hypertrophied,  the 
glands  and  muscular  fibers  atrophied,  the  bronchi 
dilated  into  bronchiectases;  or  the  mucous  struc- 
tures may  be  infiltrated  by  spurious  hypertrophy, 
the  interglandular  connective  tissue  hyperplastic 
and  the  surface  glandular.  Follicular  ulceration 
is  not  uncommon,  while  the  atrophied  tissue  may 
be  in  part  replaced  by  emphysematous  dilation 
of  the  air-cells. 

Etiology. — Chronic  bronchitis  may  follow  re- 
peated acute  attacks;  underlying  it  we  may  find 
a  cachectic  or  diathetic  state,  rheumatism, 
scrofula,  uricemia,  alcoholism,  syphilis,  or 
nephritis.  It  occurs  in  the  mechanical  conges- 
tion of  the  lungs  from  obstructive  disease  of  the 
heart.  Primarily  it  occurs  from  habitual  exposure 
to  cold  or  wet,  or  the  inhalation  of  irritant  vapors 
or  dust.  It  is  common  in  old  age.  It  is  worse  in 
winter,  in  wet  seasons,  when  sudden  changes  occur 
in  the  weather,  and  during  or  after  epidemics  of 


138         THE  DISEASES   OF  THE  RESPIRATORY   ORGANS. 

influenza.  It  tends  to  subside  in  tlie  summer, 
reappearing  earlier  each  fall  and  lasting  later  each 
successive  spring. 

Symptoms. — A  sense  of  weight  may  be  felt  in 
the  chest.  If  the  mucus  is  adhesive  or  abundant 
the  cough  may  be  so  violent  as  to  cause  soreness 
from  straining  the  insertions  of  the  diaphragm. 
The  accessory  muscles  of  respiration,  the  sterno- 
cleido-mastoids,  scaleni,  etc.,  in  time  become 
hypertrophied  by  the  violent  coughing,  and  stand 
out  plainly  from  the  shrunken  tissues  around 
them.  Cough  is  more  violent  if  the  secretion  is  in 
the  larynx  or  the  smaller  bronchi.  It  is  less 
marked  in  old  age  when  the  bronchial  sensibility 
is  low  and  secretions  accumulate.  When  chilling 
or  other  causes  induce  an  exacerbation  of  the 
malady  the  cough  is  worse. 

The  sputa  vary.  There  may  be  thick,  scanty 
adhesive  mucus,  free  muco-pus,  starchy  or  gelat- 
inous, dried  greenish  scabs,  decomposed  fetid 
plugs,  or  the  serous  discharge  of  acute  mycosis  or 
bronchorrhea.  There  may  be  a  little  fever  to- 
wards evening,  but  this  symptom  usually  indicates 
an  acute  attack  or  extension  of  the  inflammation 
into  the  lung-tissues.  The  general  health  may 
remain  tolerably  good  for  many  years,  the  diges- 
tion fair,  but  the  sleep  is  disturbed  more  or  less 
by  cough.  The  tendency  is  for  the  malady  to 
extend.    Dyspnea  may  be  marked,  or  wanting. 


CHRONIC   BRONCHITIS.  189 


The  thorax  expands,  the  respiratory  movement 
is  limited  in  range.  The  percussion  sound  is  clear 
while  auscultation  gives  rales  of  every  degree  of 
fineness  and  coarseness  depending  on  the  mucus 
present.  Often  loud  bubbling  is  heard  over  both 
lungs,  the  patient  coughs  up  a  mass  of  sputa,  and 
then  the  sounds  cease.  The  vesicular  sound  is  apt 
to  be  weak,  rough,  expiration  prolonged  and  wheez- 
ing. Dullness  on  percussion  indicates  edema, 
pleuritic  effusion  or  invasion  of  the  lung-sub- 
stance. 

In  the  aged  the  most  common  form  is  the  win- 
ter-cough, occuring  earlier  each  autumn  and  stay- 
ing later  each  spring.  Emphysema,  dyspnea  worse 
on  exertion,  and  sometimes  but  not  necessarily 
cardiac  disease  or  weakness,  may  be  present.  The 
sensibility  of  the  mucosa  is  dulled,  and  the  sputa 
may  be  retained  until  decomposition  occurs,  with 
fetid  sputa,  toxic  inflammation  of  the  bronchi  and 
lung-tissue  underneath,  fever,  somnolence,  sapre- 
mia,  carbonic  poisoning  and  sometimes  unex- 
pectedly sudden  death. 

In  bronchorrhea  there  is  a  very  profuse  dis- 
charge, of  serum  if  colliquotive  or  mycotic,  of 
muco-pus  in  late  stages  of  the  malady.  Greenish 
masses  of  more  consistence  are  discharged  from 
the  dilated  bronchi. 

Fetid  bronchitis  may  develop  in  any  case  if  the 
secretions  are  not  coughed  out.    Acute  septic  in- 


140         THE  DISEASES   OF  THE  RESPIRATORY   ORGANS. 

flammation  ending  in  ulceration  of  the  surfaces 
bathed  in  the  decomjoosing  secretions  follows^  or 
pulmonary  gangrene  may  ensue,  or  empyema  from 
perforation  or  extension  to  the  pleura.  In  simple 
fetid  bronchitis  the  sputa  on  standing  separates 
into  three  layers,  frothy  mucus,  a  serous  liquid 
and  a  thick  sediment,  containing  yellowish  masses 
termed  "Dittrich^s  plugs."  These  contain  numer- 
ous micro-organisms,  especially  the  leptothrix  pul- 
monalis,  with  fat,  margarin  crystals  and  pus-cells. 
The  general  symptoms  are  grave — rigors,  chills, 
septic  fever,  rapid  weak  pulse,  heavy  sweats  and 
rapid  prostration  of  the  vital  powers  follow  quickly. 
If  the  irritating  products  reach  healthy  mucous 
surfaces  great  irritation  and  violent  coughing  en- 
sue.   The  result  depends  entirely  on  the  treatment. 

In  dry  forms  of  catarrh  the  secretion  is  scanty 
and  adhesive,  the  cough  incessant  and  dyspnea 
often  marked.  Emphysema  is  a  common  concomi- 
tant. The  rales  are  dry,  sibilant,  and  sonorous. 
This  is  the  most  frequent  in  elderly  subjects,  the 
thin,  dried-up  species. 

Elderly  women  are  liable  to  a  chronic  bron- 
chitis, beginning  early  in  life  with  slight  symp- 
toms, morning  cough,  little  expectorations,  no  spe- 
cial physical  signs,  becoming  worse  with  years. 
Uricemia  or  scrofula  may  underlie.  Anders  men- 
tions a  case  where  bronchitis  and  eczema  alter- 
nated in  an  arthritic  woman. 


CHRONIC   BRONCHITIS.  141 

DiAG>;osis. — Phthisis  is  distinguished  by  the 
history,  the  loss  of  flesh  and  strength,  fever,  signs 
of  distress  localized  (usually  at  the  apex),  and 
the  presence  of  the  characteristic  tubercle  bacilli 
in  the  sputa. 

In  pure  emphysema  there  is  increased  clearness 
on  percussion,  weak  vesicular  sounds,  dyspnea  in- 
creased on  exertion,  obstruction  of  the  pulmonary 
circulation  if  extensive,  dilation  of  the  clavicular 
or  intercostal  spaces,  and  the  history  and  cause  of 
that  malady.  , 

In  pulmonary  abscess  the  sputa  contain  shreds 
of  elastic  fiber,  crystals  of  hematoidin  and  chlos- 
terin,  blood-pigment  masses,  and  the  site  of  the 
abscess  is  denoted  by  dullness  before  evacuation, 
cavernous  sounds  afterwards.  No  elastic  fibers 
are  found  in  gangrene,  the  ferment  present  caus- 
ing their  solution,  but  the  prostration  is  extreme. 
Bronchiectases  are  usually  on  one  side  only ;  the 
physical  signs  of  a  cavity  are  present,  the  history 
pointing  to  this  rather  than  to  tuberculosis,  and 
the  sputa  examination  confirming  the  diagnosis. 

Prognosis. — The  victim  of  chronic  bronchitis 
rarely  recovers  unless  he  removes  to  a  suitable 
climate  in  the  tropics.  The  malady  may  not 
shorten  life,  unless  emphysema  or  heart-disease 
supervenes,  or  a  microbic  invasion  carries  some 
disease  into  the  lung-structures. 

Treatment. — As  the  infection  is  worse  in  win- 


142  THE  DISEASES   OF  THE  RESPIRATORY   ORGANS. 

ter  and  nearly  or  wholly  disappears  in  the  warm 
season,  whenever  it  is  possible  the  patient  should 
be  sent  to  live  in  a  land  of  perpetual  summer, 
where  there  is  the  least  likelihood  of  catching  cold 
from  changes  in  the  weather.  In  other  cases 
some  protection  is  secured  by  hardening  the  skin, 
by  daily  cold  baths  or  salt  rnbs,  wearing  woolen 
clothes  exclusively,  night  and  day,  summer  and 
winter,  outside  and  inside,  head  to  feet;  in  fact 
the  "Jaeger  system^^  in  its  entirety.  The  avoid- 
ance of  exposure  to  cold  and  wet  should  be  incul- 
cated as  a  duty.  Epidemics  of  influenza  mu.st  be 
escaped  from  with  the  utmost  speed.  The  inhala- 
tion of  irritants  must  be  avoided;  crowded  halls, 
smoky  saloons,  overfilled  cars  on  damp,  humid 
days,  being  common  causes  of  acute  exacerbations. 
Patients  with  profuse  purulent  secretion  should  be 
sent  to  the  pine  woods,  those  with  scanty  tough 
sputa  to  the  seaside,  while  anemic  cases  with  serous 
bronchorrhea  should  ascend  to  the  mountain  re- 
sorts. In  all  cases  an  equable  temperature  should 
be  sought.  The  hot,  dry  plains  of  Arizona  suit 
cases  with  free  secretion,  while  the  Florida  coast 
offers  a  suitable  site  for  dry  catarrhs.  Among  the 
islands  of  our  Philippine  possessions  and  in 
Porto  Eico  ideal  locations  could  be  found  for  all 
classes  of  sufferers  with  chronic  pulmonary  com- 
plaints. 


CHRONIC   BRONCHITIS.  143 

Coexistent  disease  of  the  heart,  lungs  or  kid- 
neys, should  receive  appropriate  treatment. 

Much  may  be  done  by  judicious  diet  and  con- 
stitutional treatment,  especially  in  diathetic  cases. 
In  uricemia  the  enforcement  of  the  vegetarian 
regime,  with  the  alimentary  canal  kept  free  by 
saline  laxatives,  asceptic  by  zinc  and  sodium  or 
calcium  sulphocarbolate,  three  decigrams  (gr.  5) 
three  to  seven  times  a  day,  the  eliminatives  active 
by  colchicine  half  a  milligram  (gr.  1-134)  two 
to  six  times  a  day,  with  full  exercise,  will  greatly 
enhance  the  effect  of  direct  medication.  In 
scrofula,  tuberculosis,  cachexias  generally,  where 
there  is  a  basal  fragility  of  the  cell-walls  and  con- 
sequent disposition  to  fall  into  disease  easily,  with 
little  power  to  set  up  healthy  repair,  the  calcium 
salts  are  indicated,  the  sulphocarbolate  as  an  in- 
testinal antiseptic,  three  decigrams  (gr.  5)  three 
to  seven  times  a  day ;  the  lactophosphate  in  similar 
doses  to  restrain  colliquative  discharges;  the  sul- 
phide, three  centigrams  (gr.  1-3)  every  hour  or 
two  to  check  pus-formation;  the  hypophosphite, 
a  decigram  (gr.  11-2)  every  waking  hour  as  a 
tissue-builder,  to  be  continued  for  months  or  years 
if  necessary. 

Anemia  is  best  met  by  iron  arsenate,  a  milli- 
gram (gr.  1-67),  and  iron  phosphate  a  centigram 
(gr.  1-6),  repeated  every  waking  hour. 

When  the  secretions  are  scanty  and  dry  the 


144  THE  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

remedies  indicated  are  those  that  increase  and 
liquefy  the  sputa,  the  best  being  the  inhalation  of 
steam,  with  lobelin  or  emetin  internally,  one  to 
five  milligrams  (gr.  1-67  to  1-12)  every  vs^aking 
hour,  stopping  when  the  desired  effect  is  mani- 
fested or  nausea  supervenes. 

If  the  secretion  is  profuse  and  purulent,  cal- 
cium sulphide  three  centigrams  (gr.  1-2),  strych- 
nine arsenate  one  milligram  (gr.  1-67),  and  mac- 
rotin  one  centigram  (gr.  1-6),  should  be  given 
together  every  waking  hour  till  full  effect,  as  in- 
dicated by  the  odor  of  calcium  sulphide  on  the 
breath,  slight  strychnine  twitching,  or  physiologic 
tonicity  of  the  heart  from  the  macrotin.  The  lat- 
ter with  the  strychnine  is  intended  to  tone  up  the 
relaxed  mucous  tissues  and  thus  check  the  abnor- 
mal output  of  secretion.  Possibly  hydrastine  sul- 
phate one  milligram  (gr.  1-67),  added  to  each 
dose,  would  aid  in  this  respect,  but  this  drug  has 
won  repute  especially  as  a  tonic  of  the  gastro- 
intestinal mucosa.  In  regard  to  all  the  remedies 
suggested  the  doses  given  are  average  and  should 
be  increased,  diminished  or  suspended,  according 
to  the  effects  manifested. 

If  the  secretion  is  serous  and  profuse,  there 
may  be  a  general  broncho-pulmonary  mycosis  pres- 
ent, or  the  flow  is  colliquative,  alternating  with  a 
similar  flow  from  the  skin  or  the  bowels.  In  the 
former  cases  calcium  sulphide  must  be  pushed  to 


CHRONIC    BRONCHITIS.  145 

full  toleration,  with  europhen  or  iodoform  one  to 
six  centigrams  (gr.  1-6  to  1),  every  hour,  to 
destroy  the  micro-organisms;  while  sprays  of 
europhen  in  fluid  petrolatum,  one  part  to  eight, 
preceded  by  complete  cleansing  of  the  pulmon- 
ary tract  by  five  minutes'  inhalation  of  the  fumes 
of  boiling  vinegar,  should  be  repeated  every  two 
hours.  Other  antiseptic  sprays  have  not  given 
me  as  good  results,  though  one  of  camphor  and 
menthol  1  1-3  grams  each  (23  grains),  thymol 
1-2  gram  (7  1-2  grains),  and  fluid  petrolatum  30 
grams  (1  oz.),  has  often  proved  a  valuable  adjuv- 
ant. Strychnine  to  full  tolerance,  a  highly  nutri- 
tious diet,  the  air  of  the  room  charged  with  the 
vapor  of  the  oil  of  cloves  or  cinnamon,  are  also 
indicated. 

When  the  bronchorrhea  is  colliquative  the  fever 
should  be  checked  by  calcium  sulphocarbolate  three 
decigrams  (gr.  5),  every  hour  or  two,  with  equal 
doses  of  calcium  lactophosphate  which  is  almost 
a  specific  here,  and  guaiacol  externally,  five  to  ten 
drops  diluted  with  cod-liver  oil  rubbed  into  the 
skin  over  the  lung.  The  body  should  be  sponged 
with  vinegar.  Strychnine  is  required  in  full  doses, 
with  macrotin  six  centigrams  (gr.  1),  every  two 
to  four  hours.  This  powerful  stimulation  of  ton- 
icity will  generally  rouse  the  failing  powers  and 
keep  the  patient  alive  a  while  longer.  And  in  these 
cases  he  wants  every  hour  of  life  he  can  secure  and 


146  THE   DISEASES    OF    THE    RESPIRATOkY    dE.GaT^S. 

is  grateful  for  every  day  tliat  he  is  kept  alive, 
though  def,th's  pinions  hover  over  him  continually. 

When  the  sensation  of  the  bronchial  mucosa  is 
lost  and  the  secretions  collect,  with  cyanosis, 
drowsiness,  etc.,  sanguinarine  nitrate  is  the  most 
effective  remedy  in  doses  of  one  to  three  milli- 
grams (gr.  1-67  to  1-20),  every  one  to  two  hours, 
until  the  patient  is  coughing  sufficiently  to  rid  his 
tubes  of  the  redundant  secretions.  Scillitin,  sene- 
gin,  aristolochin  and  ammonia  act  similarly  but 
are  less  efficient. 

If  on  the  contrary  the  cough  is  excessive  and 
there  is  little  or  no  secretion  to  be  expelled,  the 
sedatives  are  required,  codeine  half  to  one  centi- 
gram (gr.  1-12  to  1-6) ;  zinc  cyanide  one  to  three 
milligrams  (gr.  1-67  to  1-20),  the  best  and  most 
manageable  of  the  cyanide  remedies;  or  Dover's 
powder  as  modified  by  me,  substituting  camphor 
monobromide  for  the  potassium  sulphate  and  the 
alkaloids  for  the  opium  an  ipecac.  The  inhalation 
of  steam  is  again  a  most  essential  remedy.  Mur- 
rell  advises  spraying  with  wine  of  ipecac,  and  I 
have  utilized  the  suggestion  but  substituted  a 
watery  solution  of  emetin  instead,  two  decigram.s 
(gr.  3),  to  thirty  grams  (1  oz.),  of  water.  The 
atomization  of  fluid  petrolatum  is  also  very  sooth- 
ing. A  full  dose  of  atropine,  one-half  milligram 
(gr.  1-134),  will  often  check  the  irritation,  espe- 
cially if  the  presence  of  marked  dyspnea  indi- 


CHRONIC   BRONCHITIS.  147 

cates  the  predominance  of  the  spasmodic  element. 
Counter-irritation  over  the  pncumogastric  nerve 
in  the  neck  also  often  gives  great  relief. 

Of  the  remedies  usually  administered  for  bron- 
chitis very  few  are  given  with  a  definite  idea  of 
their  true  effects.  A  mixture  is  made  of  a  number 
of  the  so-called  expectorants,  often  antagonistic; 
these  are  swallowed  at  lengthy  intervals,  until  time 
has  cured  the  patient  or  established  the  chronic 
malady.  Ipecacuanha  and  cocillana  relax  the  con- 
gested tissues,  lessen  hyper-sensitiveness  and  pro- 
mote secretion.  Squill  and  senega  increase  sensi- 
tiveness and  aggravate  the  cough,  increasing  con- 
gestion. Tolu,  copaiba,  myrrh,  the  balsams  and 
cubeb,  check  secretion,  leaving  an  acute  conges- 
tion unrelieved,  but  are  effective  in  restraining 
profuse  muco-purulent  discharge.  They  have  some 
effect  also  in  clearing  away  the  "dregs"  of  an 
attack,  when  it  threatens  to  become  chronic. 
Sugar,  licorice,  gums  and  mucilages,  soothe 
pharyngeal  irritation.  I  have  given  ammonium 
many  times  and  have  found  no  place  for  any  of  its 
salts  that  is  not  better  filled  by  the  agents  above 
mentioned. 

In  fetid  bronchitis  the  volatile  oils  are  of  great 
value,  stimulating  the  imperiled  tissues  to  throw 
off  the  impending  death.  Oil  of  turpentine,  eu- 
calyptus, cajeput  or  sandal,  should  be  given  in 
doses  of  one-half  to  one  gram   (seven  to  fifteen 


148  THE  DISEASES  OF  THE  RESPIRATORY   ORGANS. 

minims),  in  capsule  every  one  to  three  hours. 
Whether  these  agents  are  actually  capable  of  stop- 
ping a  pulmonary  gangrene  once  begun  is  perhaps 
doubtful,  but  there  is  no  more  effective  treatment 
known.  Strychnine  arsenate  should,  however,  be 
pushed  to  full  toleration,  two  milligrams  (gr. 
1-30)  every  one  to  three  hours;  while  the  richest 
diet  is  to  be  ordered  that  the  patient  can  take. 
Sprays  of  carbolic  acid,  1-2  to  1  per  cent  in  dis- 
tilled water,  should  also  be  used  often  enough  to 
prevent  fetor  of  the  breath. 

Pulmonary  gymnastics  may  be  of  great  value. 
When  any  micro-organisms  are  found  in  the  sputa 
against  which  we  have  a  known  antidotal  serum, 
it  should  be  employed.  As  the  antistreptococcic 
serum  is  only  available  against  the  streptococcus 
from  which  it  was  derived,  and  there  are  many 
varieties  of  streptococcus,  the  most  effective 
method  would  be  to  prepare  the  serum  from  cocci 
obtained  from  each  patient's  sputa  for  use  in  that 
case  alone.  Meanwhile  calcium  sulphide  is  the 
best  universal  germicide  for  internal  use. 

The  careful  regulation  of  the  patient's  habits 
and  personal  hygiene,  the  discriminating  selection 
of  the  remedies  appropriate  to  the  conditions  pres- 
ent, the  scientific  rebuilding  of  the  vital  forces, 
will  give  the  best  obtainable  results. 


CHAPTER  XXIV. 

BRONCHIECTASIS. 

Two  forms  of  bronchial  dilatation  are  found, 
the  cylindrie  and  the  saccular.  The  dilated  tubes 
form  sacs,  with  smooth  walls,  communicating  to 
form  compound  cavities,  of  all  sizes.  The  cylin- 
drie epithelium  lining  normal  bronchi  is  replaced 
by  tesselated  cells.  The  subepithelial  tissues 
atrophy.  Secretions  lying  in  these  cavities  de- 
compose causing  irritation,  inflammation,  ulcera- 
tion and  the  symptoms  consequent. 

Etiology. — Whenever  a  disease  exists  in  the 
thorax  that  causes  destruction  of  a  part  of  the 
lung-tissue  or  its  compression,  nature  supplies  the 
vacuum  by  drawing  in  the  intercostal  spaces,  ap- 
proximating the  ribs,  dilating  the  air-cells  in  em- 
physema, or  the  bronchi  into  bronchiectases.  This 
process  therefore  may  follow  pleurisy  with  per- 
manent compression  of  the  lung,  pneumonia  or 
tuberculosis  with  destruction  of  tissue,  chronic 
bronchitis  with  atrophy,  and  lobular  pneumonia 
with  atelectasis.  The  weakening  of  the  bronchial 
walls  by  disease  favors  dilation.  Straining  from 
whooping-cough  is  more  likely  to  produce  em- 
physema, though  Heubner  thinks  this  affection 
and   measles   sometimes   cause   dilation.      Earely 


150  THE   DISEASES    OF   THE    RESPIRATORY    ORGANS. 

the  malady  is  congenital^  but  in  such  cases  the 
true  cause  is  probably  lobular  pneumonia.  Bron- 
chiectasis is  more  common  in  male  adults. 

Symptoms. — The  symptoms  depend  on  the 
presence  of  fluid  in  the  sacs.  If  there  is  none, 
the  only  symptom  may  be  shortness  of  breath, 
dependent  on  the  quantity  of  pulmonary  tissue 
destroyed.  More  frequently  bronchiectasis  is 
simply  an  incident  in  the  course  of  the  causal 
malady,  whose  symptoms  are  j)resent.  If  the 
cavity  fills  with  fluid  it  is  apt  to  cause  irritation 
and  persistent  cough  until  emptied.  The  sputa 
are  characteristic  of  cavity-retention,  and  are 
separable  in  layers.  Sometimes  there  is  little 
sensibility  and  the  cough  only  occurs  when  the 
patient  lies  down  or  turns  to  the  sound  side, 
when  the  contents  of  the  cavity  begin  to  flow  into 
the  trachea  and  are  coughed,  up.  Cavities  may 
exist  on  both  sides  and  be  thus  emptied  succes- 
sively. The  sputa  may  decompose  if  long  retained. 
The  consequent  ulceration  may  then  cause  hem- 
optysis. Retained  sputa  consists  of  mucus,  pus- 
cells,  Charcot-Leyden  crystals,  fat-crystals  in 
bundles,  leptothrix,  vibriones  and  various  bacteria. 
Elastic  fibers  indicate  ulceration  and  destruction 
of  the  pulmonary  parenchyma. 

The  chest-wall  is  usually  retracted.  Percussion 
is  flat,  dull  if  the  cavity  is  filled,  tympanitic  if 
empty,  abnormally  clear  sometimes  from  the  ac- 


BRONCHIECTASIS. 


151 


companying  emphysema  and  air  in  the  cavity. 
Auscultation  gives  a  weak  vesicular  sound,  and 
various  moist  rales  dependent  on  the  fluid  present. 
The  majority  of  pulmonic  cavities  are,  at  least 
in  the  beginning,  bronchiectases. 

Diagnosis. — In  bronchiectasis  there  is  a  his- 
tory of  bronchitis  or  other  causal  affection,  cough 
on  assuming  a  certain  position,  sputa  of  a  cavity, 
it  begins  at  the  base  of  the  lung  posteriorly,  there 
are  the  signs  of  cavity,  running  a  chronic  course. 


BRONCHIECTASIS. 

1            TUBERCULAR   CAVITY. 

History    of    chronic    bronchitis. 

History   of   attack,    emaciation, 

pleurisy     or     other     malady 

sweats,     hectic,     predisposi- 

with diminished   tho- 

tion,   infection. 

racic  contents. 

Cough     paroxysmal,     sputa     of 

Cough     morning     and     evening. 

cavity  copious, 

nummular    sputa. 

No  tubercle  bacilli, 

Tubercle  bacUli. 

General    health    good, 

Progressive  debility. 

Little  or  no  fever. 

Fever, 

Long  course. 

Shorter  course. 

Persistent,    quiet,    located    near 

Progressive;  near  apex. 

base    posteriorly. 

with  no  fever,  and  no  tubercle  bacilli.  Tubercular 
cavities  have  a  history  of  cough,  fever,  hemoptysis, 
sweats,  rapid  loss  of  flesh  and  strength,  hectic, 
nummular  sputa  showing  tubercle  bacilli,  rapid 
course,  signs  of  a  progressive  malady,  more  fre- 
quently beginning  at  the  apex. 

Empyema  with  pneumothorax  has  the  history 
of  pleurisy  with  sudden  discharges  of  much  puru- 
lent sputa  at  long  intervals.  Actinomycosis  is 
diagnosed  by  the  microscope. 


153  THE   DISEASES   OF  THE   RESPIRATORY   ORGANS. 

Peognosis. — That  of  the  causal  malady.  The 
supervention  of  tuberculosis  or  of  streptococcus- 
infection  is  disastrous. 

Teeatment. — The  treatment  is  of  the  causal 
infection.  The  cavity  should  he  kept  as  clean  and 
as  nearly  aseptic  as  possible,  by  the  inhalation  of 
steam,  medicated  with  benzoin,  carbolic  acid,  tur- 
pentine, thymol  or  camphor;  and  atomizing  fluid 
petrolatum  with  europhen,  1  to  8,  afterwards. 
Iodoform,  terebene  or  eucalyptol  may  be  given 
internally  with  benefit.  The  cavities  have  been 
injected  with  iodine  or  silver  solution  through  the 
chest-wall,  and  drained  by  the  surgeon,  with  great 
advantage. 


CHAPTER  XXV. 

BRONCHIAL  STENOSIS. 

The  Dronchi  may  be  narrowed  by  constriction 
in  the  walls,  or  compression  from  without.     For- 
eign   bodies,    polypi,    pulmonary    growths    and 
exudates,     aneurisms,     cysts,     tumors,     enlarged 
glands,  abscesses  and  pleural  effusions  are  among 
the    causes.      The   pressure    induces   dyspnea   in 
proportion   to    the   importance   of    the   bronchus 
compressed.     The  dyspnea  is  persistent  and  pro- 
gressive until  the  cause  is  relieved.     A  similar 
condition  obtains  to  that  seen  in  croup,  the  air  in 
the    obstructed    region   being    rarefied,    and    the 
affected    part    retracted    on    inspiration.     Other 
symptoms  depend  on  the  causal  disease.     Edema 
and  hyperemia  of  the  obstructed  lung  follow  as 
in  croup.     The  respiratory  movement  and  tactile 
fremitus  are  lessened,  percussion  clear,  vesicular 
sound  diminished,  serous    rales  supervene   with 
the   oedema.     The   diagnosis   is   made   from   the 
limitation  of   the    physical  signs,  the   history  of 
the    antecedent    affection,    and    the    absence    of 
tracheal  or  laryngeal  symptoms.     The  prognosis 
is  generally  bad.     The  treatment  is  that  of  the 
cause.     It  is  obvious  that  bolder  surgery  will  be 
the  rule  than  in  the  past  history  of  such  maladies. 


CHAPTER  XXVI. 

PULMONARY  COIVGESTIOIV. 

Passive  congestion  occurs  mechanically  as  a 
result  of  mitral  or  aortic  disease,  obstructing  the 
outflow  of  blood  from  the  pulmonary  capillaries. 
Compensatory  h3^pertrophy  of  the  right  ventricle 
sustains  the  aortic  circulation  but  increases  the 
pulmonary  congestion.  Some  cerebral  maladies 
give  rise  to  this  condition,  which  may  also  be 
caused  by  the  pressure  of  tumors  upon  the  pul- 
monary veins. 

The  blood-vessels  of  the  lungs  are  distended, 
the  lungs  swollen  and  engorged,  the  connective 
tissue  hyperplastic  in  old  cases,  the  air-cells  com- 
pressed and  oxygenation  correspondingly  dimin- 
ished.   The  process  begins  at  the  base  of  the  lungs. 

Dyspnea  is  pretty  constant,  a  sense  of  stuffiness, 
with  a  disposition  to  take  long  breaths  occasion- 
ally. This  is  worse  after  meals,  as  the  bulk  of  the 
blood  is  then  increased.  Bronchial  catarrh  de- 
velops, but  without  this  the  engorgement  causes 
constant  irritative  cough  with  serous  or  bloody 
sputa.  The  lips  are  stained  as  if  the  patient  had 
been  eating  mulberries.  Shortness  of  breath  in- 
creases with  exertion. 

The   diagnosis    is    unmistakable    when    cough. 


PULMONARY    CONGESTION.  155 

dyspnea  and  hemoptysis  with  deficient  oxygena- 
tion  coincide  with   valvular  heart-disease. 

The  term  hypostatic  congestion  is  used  to  des- 
ignate a  condition,  most  common  in  typhoid 
states,  when  the  lower  portions  of  the  lungs  be- 
come water-soaked  or  dropsical.  The  general 
vitality  is  low,  the  vesicular  tension  so  reduced 
that  the  blood-serum  oozes  through  the  vessel- 
walls  and  collects  in  the  most  dependent  parts. 
When  the  position  is  changed  the  serum  slowly 
shifts,  collecting  in  what  has  become  the  lowest 
part.  The  air-cells  and  parenchyma  become  alike 
overflowed  with  serum.  This  is  sometimes  seen 
in  aged  and  very  feeble  people,  especially  when 
in  the  last  stages  of  exhausting  disease. 

The  symptoms  may  be  unnoticeable — unusual 
weakness,  somnolence,  pulse  weak,  respiration  a 
little  hurried,  the  mouth  open  and  accessory  res- 
piratory apparatus  brought  in  use,  and  deepening 
cyanosis.  Examination  shows  the  lungs  dull  in 
the  dependent  parts,  serous  rales,  loud  or  fine, 
bronchial  breathing,  increased  fremitus,  the  signs 
shifting  when  the  patient's  position  has  been 
altered  for  a  few  hours. 

In  both  forms  of  passive  congestion  the  prog- 
nosis is  that  of  the  primary  affection. 

Treatment. — In  mechanical  congestion  the 
treatment  is  that'  of  the  causal  malady — and  in 
fine  this  means  the  reduction  of  the  heart's  work 


156  THE  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

to  the  lowest  possible  limit  by  the  imperative 
restriction  of  fluids^  so  as  to  reduce  the  bulk  of 
the  blood.  Eichardson  sought  to  relieve  the 
dyspnea  and  aerate  the  blood  by  the  use  of  hy- 
drogen dioxide  internally,  but  this  could  be  bet- 
ter done  by  disengaging  in  the  air  of  the  patient's 
room  an  extra  quantity  of  oxygen. 

Those  liable  to  hypostatic  congestion  should 
be  changed  about  every  few  hours,  the  heart  and 
arterial  tone  sustained  by  strychnine  in  full 
doses,  with  berberine,  a  centigram  (gr.  1-6) 
every  two  to  four  hours  to  increase  capillary  ton- 
icity. Apocynin  in  the  same  dose  aids  in  carry- 
ing off  the  surplus  water.  Feed  richly,  keep  the 
blood  circulating  by  massage,  with  stimulating 
liniments.  Be  wary  about  allowing  the  patient 
to  lie  half-asleep  for  long  periods.  Sanguinarine 
in  small  and  repeated  doses,  one  to  three  milli- 
grams (gr.  1-67  to  1-20)  every  two  to  four  hours, 
stimulates  the  vitality  of  the  pulmonary  tissues 
and  is  consequently  of  special  value  in  this  condi- 
tion. 


CHAPTER  XXVII. 

CHRONIC  PNEUMONIA. 

Cirrhosis  or  fibrosis  of  the  lung  occurs  in  two 
forms,  local  and  diffuse.  It  is  unilateral.  The 
history  is  that  of  cirrhosis  elsewhere — there  is 
hyperplasia  of  the  connective  tissue,  which  later 
contracts,  both  processes  being  at  the  expense  of 
the  air-cells  and  glandular  elements,  whose  space 
is  seized  first  and  which  are  choked  out  by  the 
contraction.  The  affected  part  of  the  lung  is  con- 
verted into  a  fibrous,  scar-like  mass,  occupying 
less  space  than  when  healthy.  The  vacated  space 
may  be  filled  up  by  retraction  of  the  intercostal 
and  clavicular  spaces,  emphysema,  bronchiectases, 
and  the  heart  may  even  be  drawn  over  towards 
the  affected  region.  Adhesions  of  various  de- 
grees may  form.     Tuberculosis  may  supervene. 

The  affection  is  secondary  to  various  inflamma- 
tions, tubercle,  syphilis,  hydatids,  etc.  The  dif- 
fuse form  follows  acute  pneumonia  ^vith  missed 
crisis,  influenzal  pneumonia,  pleurisy,  atelectasis 
and  especially  broncho-pneumonia. 

The  process  begins  in  the  submucous  layers  and 
extends  into  the  parenchyma.  It  may  arise  pri- 
marily or  from  the  inhalation  of  irritants. 

The  symptoms  are  cough,  expectoration,  early 


158  THE   DISEASES   OF  THE  RESPIRATORY   ORGANS. 

dyspnea,  worse  on  ascending  heights,  oppression, 
pain  if  the  pleura  are  involved.  There  is  no  fever. 
Other  symptoms  are  due  to  the  accompanying 
conditions. 

The  chest-wall  is  shrunken  or  swollen  with 
emphysema;  the  side  may  be  distorted  to  bring 
the  ribs  closer,  the  spine  curving,  the  heart  dis- 
placed. The  fremitus  is  increased,  percussion 
dull,  breathing  bronchial,  with  signs  of  bronchiec- 
tasis if  present.  Eales  depend  on  the  presence  of 
fluid. 

The  malady  is  slowly  progressive.  Acute  pneu- 
monia may  occur. 

There  is  no  known  curative  treatment.  The 
efforts  of  the  physician  should  be  directed  to  se- 
curing the  patient's  comfort^  treating  complica- 
tions and  prolonging  life. 

Thiosinamin  is  said  to  possess  the  power  of 
destroying  scars,  and  even  of  causing  the  absorp- 
tion of  urethral  strictures.  It  may  check  pul- 
monary fibrosis.  The  dose  is  half  a  gram  (gr. 
7  1-2)  in  fifteen  per  cent  alcoholic  solution,  in- 
jected into  the  gluteal  tissues.  The  severe  pain  is 
alleviated  by  drawing  the  solution  into  the 
syringe  and  then  a  few  drops  of  four  per  cent 
cocaine  solution,  which  is  thus  first  injected.  Sin- 
gularly, the  anesthetic  action  of  the  cocaine  is 
manifested  immediately.  The  dose  should  not 
be  repeated  more  than  once  a  week.     Europhen 


CHRONIC   PNEUMONIA.  159 

with  fluid  petrolatum,  one  part  to  eight,  should  be 
sprayed  into  the  lungs  daily,  as  this  agent  also 
seems  to  have  local  absorptive  powers  that  may  be 
of  value  here. 


CHAPTER  XXVIII. 
ATELECTASIS. 

The  term  atelectasis  denotes  a  permanent  col- 
lapse of  the  air-cells  forming  a  lobule.  The  af- 
fected lobnle  is  solid,  airless,  dark,  the  bronchi 
occluded  by  exudate,  but  inflatable  by  the  blow- 
pipe.    The  capillaries  are  distended. 

Etiology. — This  occurs  in  new-born  infants 
from  imperfect  distention  of  the  lungs.  In  older 
children  it  is  caused  by  stoppage  of  the  bronchial 
lumen  by  exudates,  the  air  being  absorbed  or  ex- 
pired. Compression  of  the  lung  causes  it,  even 
that  of  flatulence.  It  also  results  from  some 
cerebral  diseases,  pneumogastric  paresis,  and 
paralysis  of  the  chest-walls.  Distortions  of  the 
thoracic  cage  may  be  attended  by  atelectasis. 

The  symptoms  occur  during  the  primary  af- 
fection, w^hich  is  most  frequently  broncho-pneu- 
monia. Eespiration  is  rapid  and  shallow,  with 
dyspnea  in  older  children,  lividity  and  cold  skin 
and  extremities  in  new-born  babes.  The  pulse 
is  feeble  and  rapid,  the  cry  weak,  and  carbonic 
acid  poisoning  ensues,  insidiously  in  the  case  of 
infants. 

If  extensive,  over  the  posterior  lower  lobes, 
this  part  of  the  thorax  retracts  during  inspira- 


ATELECTASIS.  161 

tion;  the  percussion  note  is  dull,  unless  masked 
by  emphysema;  with  vesicular  murmur,  weak 
bronchial  breathing,  subcrepitant  rales. 

The  diagnosis  from  lobar  pneumonia  is  made 
by  the  location  of  the  dullness,  in  the  posterior 
part  of  both  lungs,  disseminated  through  all  parts 
but  most  marked  between  the  scapulae  and  in  the 
lower  lobes;  by  the  dyspnea  and  cyanosis,  and  thg 
absence  of  the  signs  of  true  pneumonia. 

If  the  process  is  extensive  it  is  apt  to  be  perma- 
nent, the  function  of  the  affected  tissue  being  lost. 
In  infants  it  is  a  dangerous  affection.  "With 
whooping-cough,  broncho-pneumonia  or  pleurisy, 
it  is  often  fatal.  Emphysema  simply  masks  the 
malady  and  adds  to  the  injury. 

The  treatment  is  that  of  the  causative  malady. 
Inflating  the  lung  forcibly  should  be  practiced  to 
prevent  or  relieve  the  collapse;  the  position 
should  be  changed  regularly.  Infants  must  be 
made  to  cry  vigorously.  An  effective  measure 
is  placing  the  child  in  a  warm  bath  and  squirting 
cold  water  forcibly  against  the  chest.  Sanguin- 
arine  is  useful  as  a  stimulant  to  the  cough;  the 
dose  being  0.0005  (gr.  1-134)  every  half-hour  to 
a  child  two  years  old. 


CHAPTER  XXIX. 

EMPHYSEMA. 

Interlobular  emphysema  is  due  to  rupture  of 
the  air-cells,  the  air  escaping  into  the  connective 
tissue.  It  may  be  due  to  wounds,  violent  cough- 
ing or  sneezing  and  other  strains.  The  most  com- 
mon locality  is  the  clavicular  region,  which  may 
puff  up  with  escaped  air.  This  may  penetrate 
the  pleura,  or  the  subdermal  tissue  over  the  entire 
body. 

Vesicular  emphysema  is  a  simple  dilation  of  the 
air-cells  without  rupture.  It  is  termed  compen- 
satory when  it  aids  in  filling  up  the  vacuum 
caused  by  loss  of  part  of  the  thoracic  contents. 
It  is  only  compensatory  as  to  volume,  not  as  to 
function,  as  the  enlarged  cell  aerates  but  little 
more  blood  than  the  small,  and  not  nearly  as 
much  as  the  group  of  cells  normally  occupying 
the  same  space. 

Hypertrophic  emphysema  is  due  to  permanent 
dilatation  of  the  air-cells,  by  overstretching.  The 
lungs  do  not  collapse  when  the  pleura  is  opened. 
Presumably  there  is  in  these  cases  a  congenital 
deficiency  of  the  elastic  tissue. 

The  thorax  becomes  barrel-like,  the  lung-tissue 
anemic,  pitting  on  pressure.     The  cells  are  nota- 


EMPHYSEMA.  168 

bly  large,  of  various  sizes,  pleura  pale,  showing 
patches  devoid  of  pigment  (Virchow's  alhinism). 
The  septa  are  thinned  and  broken,  the  cells  coales- 
cing, the  elastic  fibers  broken  or  atrophied,  the 
capillaries  disappear,  the  epithelium  becomes 
fatty.  The  muscular  fibers  may  become  hyper- 
trophied.  The  larger  blood-vessels  are  enlarged. 
Bronchial  catarrh  usually  coexists,  with  cirrhosis 
and  bronchiectasis.  The  diaphragm  is  depressed, 
the  heart  lowered,  its  cavities  dilated  or  hyper- 
trophied,  the  pulmonary  arteries  enlarged  and 
atheromatous.  Other  viscera  show  the  effects  of 
prolonged  venous  engorgement. 

Etiology. — Emphysema  in  the  upper  lobes  de- 
velops in  whooping-cough,  bronchitis,  etc.,  from 
the  violent  strain  of  coughing  while  the  glottis  is 
closed.  Asthma,  playing  wind-instruments,  black- 
smithing,  and  other  occupations  involving  similar 
pulmonary  strain,  cause  emphysema.  The  loss 
of  elasticity  and  atrophy  of  the  tissues  in  old  age 
give  rise  to  a  harmless  emphysema,  and  if  con- 
tracted in  childhood  it  reappears  in  old  age. 

Symptoms. — Emphysema  being  not  so  much  a 
distinct  disease  as  a  process  entering  into  the 
clinical  history  of  various  maladies,  its  symptoms 
are  those  of  the  latter.  It  slowly  develops  from 
occupations,  but  occurs  suddenly  as  an  accident 
from  unusual  strains.  It  causes  dyspnea,  dry 
cough,    perhaps    cyanosis,    the    breathing-power 


164         THE  DISEASES   OF   THE  RESPIRATORY   ORGANS. 

lessens  on  exertion  or  after  full  meals,  becoming 
worse  as  the  malady  increases.  Expiration  is 
laborious  and  prolonged.  In  advanced  cases  the 
cyanosis  becomes  extreme.  Expectoration  de- 
pends on  the  coexistence  of  catarrh,  which  is  a 
frequent  concomitant,  acute  attacks  developing  a 
cyanosis  not  usual  to  bronchitis  alone.  There 
is  no  fever,  the  pulse  is  normal  or  weak,  the  tem- 
perature subnormal.  The  patient  becomes  thin, 
weak,  stooping,  cachectic.  The  right  ventricle 
hypertrophies  to  force  the  blood  through  the 
fewer  capillaries. 

Besides  the  barrel  chest,  the  winged  scapula; 
are  characteristic,  and  a  belt  of  dilated  venules 
may  be  seen  around  the  lower  border  of  the 
ribs  and  cartilages.  Hyper-resonance  is  present, 
the  vesicular  sound  is  weak,  expiration  prolonged, 
and  the  cardiac  dullness  is  obscured  by  overlap- 
ping lung.  The  unaffected  parts  give  a  harsh 
vesicular  murmur.  Bronchitic  rales  are  usually 
present,  with  those  due  to  any  other  complica- 
tion. Dry  crumpling  sounds  may  be  heard,  or 
Laennec's  rale,  resembling  the  subcrepitant. 

The  diagnosis  is  made  from  the  history,  occu- 
pation, dyspnea,  cyanosis,  barrel  chest  and  other 
signs.  Pneumothorax  develops  suddenly,  uni- 
laterally, with  violent  dyspnea,  clear  tympanic 
note,  amphoric  breathing,  soon  followed  by  the 
splashing  of  liquid. 


EMPHYSEMA.  165 

Acute  emphysema  is  curable,  the  chronic  form 
permanent  and  usually  progressive,  though  the 
symptoms  may  be  checked  or  show  improvement 
under  treatment.  Patients  are  carried  off  by  in- 
tercurrent disease,  dropsy,  hemoptysis,  or  sudden 
dilation  and  failure  of  the  right  ventricle. 

Tkeatment. — Eemove  the  cause.  Treat  the 
bronchitis.  Potassium  iodide  has  long  been  rec- 
ognized as  exerting  a  remarkably  beneficial  in- 
fluence over  emphysema.  The  dose  is  one  gram 
(gr.  xv),  thrice  daily.  The  causal  occupation 
or  habits  must  be  given  up.  Cough  must  be  held 
in  check,  colds  prevented,  asthma  relieved,  the 
bowels  kept  soluble,  flatulence  guarded  against, 
and  the  nutrition  sedulously  maintained.  The 
heart  must  receive  careful  attention.  Sudden 
and  urgent  dyspnea  may  require  venesection. 
Mechanical  compression  of  the  chest,  by  hand 
or  apparatus,  has  proved  of  service.  Inhaling 
compressed  air  and  exhaling  into  a  partial 
vacuum  is  a  promising  method.  When  cyanosis 
becomes  distressing,  arrangements  should  be  made 
for  oxygen  inhalation  of  the  patient's  conven- 
ience. Patients  with  emphysema  are  thought  to 
do  well  in  Minnesota,  even  in  winter. 


CHAPTER  XXX. 
PNEUMONOKOIVIOSIS. 

Men  who  work  in  coal-mines  inhale  the  carbon 
as  dust;  it  is  deposited  in  the  kings  faster  than 
the  mucous  cells  can  dispose  of  it,  penetrates  the 
perivascular  lymph-spaces,  is  enveloped  in  the 
leucocytes,  and  conveyed  to  the  lymph-nodules, 
interlobar  spaces  and  lymphatic  glands.  Catarrh 
with  emphysema  may  occur.  More  often  inter- 
stitial inflammation  is  set  up,  resulting  in  fibrosis. 
Some  of  the  indurated  areas  may  soften,  and  then 
ulcerate  if  air  is  admitted.  This  ends  in  tuber- 
culosis. All  city-dwellers  have  some  degree  of 
this  anthracosis,  but  not  to  an  injurious  extent. 

Chalicosis,  stone-cutter^s  consumption,  occa- 
sions a  similar  affection.  Tool-grinders  suffer  still 
more  acutely.  Siderosis  applies  to  the  malady 
as  exhibited  by  dyers.  Grain-shovelers,  cigar- 
makers,  cotton-spinners,  millers,  and  all  workers 
in  dust-laden  atmospheres  suffer  similar  maladies, 
th^  symptoms  varying  with  the  nature  of  the  dust 
inhaled.  Polishers  in  watch-case  factories,  in- 
haling rouge,  seem  also  specially  liable  to  epi- 
lepsy. 

The  symptoms  are  those  of  bronchitis  of  vary- 
ing grades,  generally  chronic.     Emphysema  fol- 


PNEUiMONOKONIOSIS.  167 

lows.  The  sputa  contain  the  dust,  muco-jous, 
and  in  due  time  the  tubercle  bacillus.  The  mi- 
croscopic examination  and  the  history  suffice  for 
the  diagnosis.  The  prognosis  depends  on  the  stage 
the  malady  has  reached  and  the  ability  of  the 
sufferer  to  secure  healthier  occupation. 

Teeatmext. — One  of  the  finest  object-lessons  is 
secured  by  covering  the  nose  and  mouth  with  a 
respirator  of  wet  flannel,  and  breathing  through 
it  the  air  of  the  workshop.  In  a  short  time  the 
respirator  is  so  clogged  that  it  must  be  renewed, 
or  washed  out  and  replaced.  Its  use  prevents 
the  malady.  K'owadays  many  shops  are  properly 
ventilated  and  free  from  this  evil.  In  others  the 
owners  advise  the  use  of  respirators^  but  find  it 
difficult  to  induce  work-people  to  use  them.  When 
the  disease  has  begun  the  patient  must  leave  the 
dusty  shop  for  a  fresh-air  occupation.  The  treat- 
ment is  that  of  bronchitis,  etc. 


CHAPTER  XXXI. 
PULMONARY  CANCER. 

All  forms  of  cancer  occur  in  the  lungs,  nsually 
secondarily  to  its  development  elsewhere,  the  in- 
fection (?)  being  carried  by  the  blood  or  lymph- 
vessels,  or  by  extension  directly.  The  causes  are 
those  of  cancer  in  general. 

The  symptoms  are  pain,  especially  when  the 
pleura  is  involved,  inflammation  excited  by  the 
growth,  dyspnea  and  cyanosis.  If  the  growth 
compresses  the  heart  or  great  vessels  the  circu- 
lation is  disturbed;  pressure  on  the  oesophagus 
causes  dysphagia,  on  the  recurrent  laryngeal 
nerve  hoarseness  or  aphonia,  on  the  trachea 
dyspnea,  etc.  The  sputa  contain  blood,  and  may 
resemble  currant- jelly,  or  be  grass-green  or  pu- 
trid. The  tumor  causes  dullness  and  loss  of  the 
vesicular  murmur;  the  thorax  may  be  pressed 
out  or  perforated,  the  superficial  veins  engorged, 
and  oedema  appears  in  the  obstructed  area'.  The 
cervical  or  axillary  glands  may  be  involved. 

The  diagnosis  is  made  from  the  existence  of 
cancer  elsewhere,  and  the  evidence  of  a  thoracic 
tumor,  steadily  increasing,  causing  irritation  and 
pressure-symptoms,  by  the  cancerous  sputa,  the 
lymphatic  glands  being  involved.     The  prognosis 


PULMONARY    CANCER.  169 

is  bad.     The  treatment  simply  means  relief  of 
pain — morphine  and  chloroform  ad  lib. 

What  has  been  said  of  carcinoma  applies  as 
well  to  sarcoma,  save  that  the  course  is  usually 
more  rapid.  Among  cobalt-miners  there  has  been 
found  a  form  of  pneumonokoniosis  attended  in 
some  cases  with  the  development  of  slowly  grow- 
ing lympho-sarcomas,  with  secondary  growths  in 
the  lymphatic  glands,  liver,  spleen  and  pleura. 


CHAPTER  XXXII. 
PULMONARY  HYDATIDS. 

Primary  pulmonary  hydatids  are  exceedingly 
rare,  secondary  ones  very  rare.  The  symptoms 
are  those  of  the  original  development,  usually  in 
the  liver,  with  pain,  cough,  dyspnea,  sometimes 
bloody  sputa,  and  the  physical  evidences  of  the 
developing  tumor.  The  characteristic  hooklets 
may  be  expectorated.  The  cysts  may  discharge 
through  the  bronchi  or  the  serous  sacs,  or  ex- 
ternally, causing  inflammation  in  their  path.  It 
is  a  dangerous  affection. 

The  treatment  is  surgical. 


CHAPTER  XXXIII. 

CHRONIC  PLEURISY. 

Chronic  serous  pleurisy  may  follow  the  acute 
form  or  develop  insidiously.  There  may  be 
scarcely  any  symptoms  except  dyspnea  on  exer- 
tion, perhaps  a  sense  of  fullness  in  the  chest,  an 
occasional  long-drawn  inspiration.  The  pulse 
may  be  faster  and  slight  evening  fever  be  pres- 
ent, with  some  fall  in  the  patient's  strength  and 
in  his  weight.  The  malady  may  develop  into 
empyema,  especially  in  children.  The  affection 
runs  on  for  months  or  years,  and  may  end  in 
tuberculosis. 

Chronic  dry  pleurisy  may  also  follow  the  acute 
or  chronic  serous  form.  The  fluid  is  absorbed 
rapidly  at  first,  more  slowly  as  it  thickens,  the 
pleura  come  together  and  adhere^  forming  a 
fibrous  capsule  compressing  the  lung. 

Some  cases  are  dry  from  the  start,  and  may 
present  no  symptoms  of  effusion.  The  pleura 
adhere,  the  respiratory  motion  is  restricted,  the 
sounds  are  weak,  the  other  lung  is  hypertrophied, 
the  heart  displaced,  spine  curved,  thorax  dis- 
torted. Sometimes  vasomotor  equilibrium  is  dis- 
turbed, flushing  or  sweating  unilaterally,  or  dila- 
tation of  the  pupil,  occurring. 


m 


THE  DISEASES  OF  THE  RESPIRATORY   ORGANS. 


The  treatment  looks  to  removal  of  effusions  if 
present  and  improvement  of  nutrition.  Carefull}- 
regulated  diet,  gymnastics,  the  pulmonary  and 
hygienic  regime  in  general,  and  climatotherapy, 
are  the  leading  indications.  The  tonics,  di- 
gestives, reconstructives  and  absorbents,  are  re- 
quired when  indicated.  Cases  vary  too  much  for 
a  fixed  line  of  treatment.     The  persistent  action 


PLEURAL  EFFUSION. 

HYDROTHORAX. 

History  of  pleurisy. 

General  dropsy. 

Unilateral, 

Bilateral. 

Effusion    following     change     of 

Fluid  follows  change  of  posture 

posture   only   at  first,    being 

throughout.     No  inflam- 

soon   encysted    by    adhe- 

matory adhesion. 

sion  of  pleura. 

No  fever. 

Fever. 

Heart    in   normal    position,    but 

Heart  displaced. 

muffled  by  pericardial 

effusion. 

of  arsenic,  mercury  and  iron  iodides,  in  moderate 
doses  continued  for  many  months,  gradually 
brings  about  absorption  of  the  effusion.  Iron 
iodide  one  centigram  (gr.  1-6),  with  a  milligram 
(gr.  1-67)  each  of  the  others,  may  be  given  three 
to  seven  times  daily;  the  bowels  and  kidneys 
being  kept  in  activity  to  stimulate  the  removal  of 
the  loosened  debris. 


CHAPTER  XXXIV. 

HYDORTHORAX. 

Hydrothorax  signifies  the  presence  of  serum  in 
the  pleura,  usually  in  both,  and  occurring  in  gen- 
eral dropsy,  especially  in  hydremia.  It  also  oc- 
curs in  chronic  diarrhea,  dysentery,  leukemia, 
pernicious  anemia,  cancer,  malaria,  syphilis, 
scurvy  and  compression  of  the  thoracic  duct. 

The  symptoms  are  dyspnea,  cyanosis,  cough, 
weak  heart,  general  debility,  with  dullness  on 
percussion,  the  fluid  shifting  with  change  of  pos- 
ture. 

The  treatment  is  that  of  the  causal  malady. 
Tapping  is  done  as  in  serous  pleurisy. 


CHAPTER  XXXV. 

CHRONIC  PHTHISIS. 

The  causes  are  those  of  the  acute  form.  The 
infection  is  less  virulent,  or  the  body  forces  more 
powerful,  and  the  malady  drags  along  for  years. 

Pathology. — The  upper  lobe  is  usually  first 
affected  near  the  apex,  the  lower  lobe  next,  then 
the  upper  lobe  of  the  other  lung.  The  left  side 
is  primarily  affected  somewhat  more  frequently 
than  the  right. 

The  primary  lesion  is  tuberculous  infiltration, 
beginning  in  the  air-cells  or  bronchioles,  which 
are  soon  obstructed  by  debris,  caseation  follows, 
then  softening,  liquefaction  forming  cavities,  in- 
creasing by  ulceration,  or  calcification  may  ensue, 
or  fibrosis.  Extinct  tubercle  may  be  surrounded 
by  zones  of  compensatory  emphysema,  or  of  cir- 
rhotic tissue. 

Tubercular  nodules  in  the  bronchial  mucosa 
may  break  down  and  the  resulting  ulcers  become 
infected  by  pyogenic  bacteria  and  spread.  The 
same  process  occurs  in  the  cavities  formed  by 
softening,  when  open  to  the  air.  In  slowly  pro- 
gressive cases,  or  when  tubercular  infection  fol- 
lows thoracic  disease  causing  loss  of  lung-sub- 
stance, bronchiectasis  may  occur,  and  the  cavi- 


CHRONIC    PHTHISIS,  175 

ties  may  increase  by  ulceration,  their  walls  break- 
ing down  under  the  influence  of  septic  matter 
collecting  in  them.  Gradually  enlarging  the 
cavities  communicate,  the  sej^ta  breaking  down, 
sometimes  forming  large  compound  cavities,  in 
which  large  masses  of  sputa  collect  and  decom- 
pose. The  effect  of  such  matter  coming  in  con- 
tact with  the  healthy  lung  and  bronchial  tissues 
adds  much  to  the  distress  and  increases  the  area 
of  the  disease. 

The  walls  of  freshly  formed  cavities  are  soft 
and  necrotic,  those  of  older  cavities  are  lined  with 
a  pyogenic  membrane,  later  becoming  exfolia- 
tive. Bronchiectases  may  present  smooth  walls. 
Large  cavities  may  be  traversed  by  fibrous  cords 
formed  of  obliterated  arteries.  Arteries  still 
previous  are  studded  with  aneurismal  dilatations, 
often  the  source  of  hemorrhages.  The  most 
common  seat  of  cavities  is  the  upper  lobe.  Small 
cavities  may  become  obliterated  by  the  contrac- 
tion of  the  fibrous  capsules.  In  this  capsule  tu- 
bercle bacilli  may  penetrate,  and  their  destructive 
work  enlarge  the  cavity,  or  fibrosis  may  extend 
into  the  surrounding  zone  of  lung-tissue,  thicken- 
ing the  protective  wall  at  the  expense  of  the  pul- 
monary parenchyma.  It  is  to  this  process  that 
the  dullness  on  percussion  is  mainly  due,  not  to 
tubercle,  which  only  occasions  dullness  when  in 
large  nodules.    Hence,  dullness  in  chronic  phthi- 


176  THE  DISEASES   OF  THE   RESPIRATORY   ORGANS. 

sis  is  usually  a  good  prognostic.  Disseminated 
miliary  tubercles  do  not  cause  dullness,  and  their 
effects  are  more  rapidly  fatal  than  those  of  isolated 
nodules,  even  if  large.  The  miliary  tubercle,  with 
its  zone  of  fibrosis  or  caseation  and  compensating 
emphysema,  when  multiplied  countlessly,  disables 
a  large  proportion  of  the  pulmonary  tissue.  The 
process  is  similar,  occurring  in  many  small  spots 
instead  of  one  large  one.  Miliary  tubercles  are 
usually  deposited  also  in  the  pleura,  bronchial 
glands,  larynx,  and  other  organs. 

Symptoms. — The  affection  comes  on  gradually 
from  a  condition  of  debility,  in  convalescence  or 
exhaustion.  There  is  evident  a  decline  in 
strength,  loss  of  weight,  anorexia,  inability  to 
digest  foods  previously  agreeable,  with  slight 
hacking  cough  of  which  the  patient  may  not  be 
conscious.  Some  fever  becomes  apparent  towards 
evening  perhaps,  with  bright  eyes,  flushed  cheeks 
and  unusual  brilliance  in  conversation.  When  at 
last  the  patient  consults  the  physician,  self-pre- 
scribed treatment  proving  futile,  there  may  be 
found  a  very  fine  rales,  heard  at  the  end  of  forced 
inspiration,  over  a  limited  area  of  one  lung,  in  the 
clavicular  spaces  in  front,  or  more  frequently  in 
the  space  uncovered  by  the  angle  of  the  scapula 
when  the  shoulders  are  drawn  forward.  Only  a 
slight  local  catarrh;  but  a  localized  catarrh  in 
the  upper  lobe  of  one  lung  is  ominous!    There  is 


CHKOiNlC    PHTHISIS.  177 

value  in  the  popular  saymg  that  a  cough  is  dan- 
gerous inversely  to  its  strength. 

In  other  cases  the  attack  opens  with  pleurisy, 
marked  indigestion,  peritonitis  or  laryngitis. 
More  acute  cases  begin  like  pneumonia,  with  reg- 
ular periodic  chills,  or  with  bronchial  hemor- 
rhage. 

Of  course  the  malady  is  so  varied  that  an 
analysis  of  the  symptoms  will  give  a  better  idea 
of  it  than  an  attempt  at  detailed  description. 

Pain  may  be  due  to  pleurisy,  straining  of  the 
diaphragm  by  severe  coughing,  aching  preceding 
hemorrhage;  or  pleurodynia  accompanying  phthi- 
sis but  not  due  to  intercostal  tuberculosis.  Ach- 
ing between  the  scapulas  is  of  diagnostic  value. 

The  cough  is  at  first  slight,  later  varies  with  the 
course  of  the  disease,  irritative  especially  if  the 
larynx  is  affected  or  when  decomposed  secretions 
flow  into  healthy  bronchi.  Cough  on  rising,  and 
later  on  lying  down,  is  characteristic.  Coming  at 
meals  it  may  cause  vomiting. 

There  is  little  or  no  sputa  at  first,  then  it  be- 
comes gray  and  sticky,  afterwards  is  yellow  or 
green,  as  pus  forms,  bloody  when  ulceration  is 
active.  The  continuance  of  gray  sputa  when  a 
bronchitic  discharge  would  have  become  yellow  is 
significant.  The  sputa  from  cavities  has  been  de- 
scribed. The  sputa  mainly  consists  of  mucus 
from  the  bronchi,  and  contains  tubercle  bacilli  and 


178  THE  DISEASES   OF  THE  RESPIRATORY   ORGANS. 

other  micro-organisms^  pus^  blood,  elastic  fibers 
when  Inng-tissiie  is  breaking  down,  fat,  food- 
particles  and  substances  inhaled. 

To  examine  for  tubercle  bacilli  select  a  grayish 
bit,  spread  evenly  over  a  cover-glass  previously 
sterilized  by  holding  in  the  flame  of  a  spirit-lamp; 
dry  over  the  lamp,  and  fix  by  passing  through  the 
flame,  stain  with  carbol  fuchsin,  decolorize  with 
nitric  acid,  wash  and  stain  with  methylene  blue. 
Viewed  with  a  1-12  oil  immersion  lens  and  Abbe 
condenser  the  tubercle  bacilli  appear  as  red  rods 
in  a  blue  field.  Many  and  repeated  examinations 
are  necessary  before  one  can  say  there  are  no 
tubercle  bacilli  in  the  sputa,  for  failure  to  find 
them  on  one  slide  does  not  prove  there  are  none 
in  the  whole  quantity.  In  collecting  sputa  for 
examination  let  the  patient  eject  that  collected  in 
the  throat  and  save  what  he  brings  up  "from  the 
bottom  of  the  lungs,'^  after  full  deep  coughing. 

To  find  elastic  fibers,  the  sputa  should  be  boiled 
in  a  solution  of  caustic  soda,  one  part  to  thirty- 
two  of  water,  and  allowed  to  settle  in  a  conical 
beaker-glass.  The  lowest  drop  can  be  taken  up 
by  a  pipette  and  placed  on  the  slide.  Fibers  from 
the  air-cells  are  interlaced,  those  from  blood-ves- 
sels or  bronchi  are  long  and  parallel.  Some  are 
branching.  They  are  relics  of  broken-down  lung- 
tissue;  the  cause  of  the  destruction  is  gathered 
from  the  symptoms. 


CHRONIC    PHTHISIS.  179 

I  have  already  discussed  the  relations  of  bron- 
chial hemorrhages,  which  may  indicate  the  pres- 
ence of  tuberculosis  or  may  be  the  cause  of  it  by 
preparing  a  suitable  soil  through  the  influence  of 
the  decomposed  blood  on  the  pulmonary  tissues. 
Profuse  hemorrhage  occurring  late  in  the  course 
of  phthisis  or  when  ulceration  is  progressing  rap- 
idly, indicates  erosion  of  an  artery.  Smaller  hem- 
orrhages are  not  uncommon  and  are  usually  bene- 
ficial, the  patient  feeling  relieved,  the  fever  and 
cough  subsiding.  Blood-spitting,  small  quanti- 
ties of  blood  in  streaks,  is  very  common  and  does 
not  necessarily  indicate  tuberculosis.  Pneumonic 
or  stained  sputa  occur  from  capillary  oozing. 
Change  of  residence  to  the  sea-shore,  or  to  an 
elevation  5000  feet  or  more  above  the  previous 
habitation,  is  apt  to  be  followed  by  a  hemorrhage. 
The  phthisical  patient  is  liable  to  engorgement  of 
the  lungs  and  consequent  hemorrhages,  from  emo- 
tion, over-eating  or  drinking,  exposure  to  cold, 
and  from  unknown  conditions.  A  sense  of  vascu- 
lar fullness,  thoracic  stuffiness,  with  pain  most 
frequently  referred  to  the  second  right  intercostal 
space  near  the  sternum  and  irritative  cough,  often 
precede  the  hemorrhage  for  one  or  several  days. 

Dyspnea  is  conspicuously  slight,  considering 
the  degree  to  which  the  respiratory  tissues  are  in- 
hibited or  destroyed.  Respiration  is  accelerated, 
however,  and  in  proportion  to  the  fever  and  the 


180  THE  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

tissue-destruction.  Unusual  exertion  quickly  dem- 
onstrates the  absence  of  a  pulmonary  reserve. 

Inspection  shows  the  thorax  flat  above,  inter- 
costal spaces  wide,  clavicular  spaces  sunken, 
lower  part  of  sternum  depressed,  scapulas  wing- 
like, the  angle  of  Louis  prominent.  The  "para- 
lytic" thorax  may  precede  or  follow  the  develop- 
ment of  phthisis.  Emaciation  is  usual,  the  skin 
soft,  elastic,  greasy,  sometimes  emitting  a  ca- 
tarrhal odor.  Expansion  is  defective  over  the  dis- 
eased area,  best  ascertained  by  palpation.  Tac- 
tile fremitus  is  increased  early.  Forced  expansion 
is  less  than  two  and  one-half  inches,  unless  the 
patient  has  trained  for  this  test. 

Dullness  on  percussion  is  evident  in  the  clavicu- 
lar spaces,  when  the  lung  below  is  consolidated. 
This  is  mainly  due  to  fibrosis.  In  one  case  of 
acute  miliary  tuberculosis  no  dullness  could  be 
demonstrated;  in  fact,  Prof.  Scott,  an  accom- 
plished diagnostician,  doubted  the  diagnosis.  The 
patient  died  within  ten  days  of  his  seizure  and 
every  part  of  the  lung  was  densely  stuffed  with 
tubercles.  Dullness  in  other  parts  of  the  lung 
alone  may  indicate  large  tubercular  nodules  or 
circumscribed  pleuritic  exudations. 

The  first  note  of  danger  may  be  a  fine  crepita- 
tion heard  at  the  apex,  or  under  the  posterior 
angle  of  the  scapula,  confined  to  a  limited  area, 
heard  at  the  end  of  a  forced  inspiration.     Pro- 


CHRONIC   PHTHISIS.  181 

longed  expiration  is  an  early  sign,  and  inspiration 
broken  into  "steps."  Sharpened  vesicular  breath- 
ing is  followed  by  broncho-vesicular  and  this  by 
bronchial.  During  the  progress  of  the  malady 
every  form  of  rale  known  may  be  heard,  crepitant, 
subcrepitant,  mucous,  submucous,  sibilant,  sono- 
rous, rhonchus,  oegophony,  pectoriloquy,  etc.,  as 
well  as  every  form  of  pleuritic  sound. 

Cavities  cause  marked  retraction  and  loss  of 
motion,  increased  tactile  fremitus  if  empty,  less 
sound-conduction  if  full,  dullness  on  percussion  if 
full  of  secretion,  tympany  if  large  and  full  of  air. 
The  note  is  louder  and  higher  pitched  if  the 
mouth  is  wide  open  (Wintrich's  sign).  The 
tympanitic  note  may  change  in  pitch  with  change 
of  posture  (Gerhardt's  change  of  sound).  The 
"cracked-pot"  sound  may  be  heard  over  large 
cavities  with  thin  walls. 

Auscultation  over  small,  lax-walled  cavities 
shows  cavernous,  low-pitched  breathing;  over 
large  tense-walled  ones  there  is  amphoric,  high- 
pitched  respiration.  Moist  rales  depend  on  the 
contents,  and  are  developed  or  altered  by  cough- 
ing. Large  cavities  with  smooth  walls  give  "me- 
tallic tinkling."  Pectoriliquy  and  amphoric  whis- 
pers are  heard  over  the  largest  cavities. 

Fever  is  present  from  the  first  and  its  height 
indicates  fairly  the  activity  and  extent  of  the  dis- 
ease process.     Chronic  forms  with  slight  or  no 


182  THE   DISEASES   OF  THE   RESPIRATORY   ORGANS. 

tubercular  infection  show  fever  towards  night 
and  a  normal  temperature  in  the  morning.  Very 
high  fever  with  hectic  and  night-sweats,  or  chills, 
indicates  streptococcus  invasion.  Cessation  of 
fever  indicates  quiescence  of  the  malady,  and  if 
continuous,  a  cure.  Sometimes  chills  occur  so 
regularly  as  to  induce  the  diagnosis  of  (quo- 
tidian) ague.  Mght-sweats  follow  fever  of  104 
or  more,  and  are  especially  marked  during  de- 
structive or  septic  stages.  Wasting  is  also  to  be 
credited  to  the  fever,  being  rapid  in  acute  forms 
and  becoming  extreme  in  subacute.  During  apy- 
retic  intervals  the  patient  may  fatten  considerably. 
Anemia  comes  from  the  fever  and  the  impairment 
of  nutrition.  The  blood  may  be  normal  or  defi- 
cient in  hemoglobin.  Leucocytosis  occurs  only  in 
septic,  suppurative  states.  Debility  is  progressive. 
Among  concomitant  phenomena  may  be  men- 
tioned tricuspid  valvular  disease,  thrush,  gastritis, 
early  hyperacidity,  later  subacidity.  Hectic 
sweats  may  alternate  with  bronchorrhea  or  colli- 
quative diarrhea.  Intestinal  tuberculosis  may  re- 
sult from  swallowing  sputa.  The  appetite  is  fee- 
ble, capricious,  the  digestive  power  small.  Anal 
fistula  is  not  common.  Albuminuria  is  common, 
and  nephritis  may  eventuate,  amyloid  or  desquam- 
ative. Pyelitis  or  cystitis  may  occur  from  second- 
ary tubercular  infections.  The  face  is  pale, 
cyanotic  sometimes  in  the  later  stages,  the  skin 


CHRONIC   PHTHISIS. 


183 


dry  and  harsh,  with  chloasma  on  the  chest,  or  pit- 
yriasis versicolor,  the  hair  extraordinarily  lux- 
uriant, the  nails  soft  or  brittle,  the  finger-ends 
clubbed. 

The  patient  is  singularly  buoyant.  The  fever 
stimulates  his  mental  faculties  to  unhealthy  bril- 
liancy. To  the  last  he  has  a  conviction  that  his 
malady  is  not  "true  consumption,"  and  that  he  is 
going  to  recover. 

Diagnosis. — The  aspect  of  the  patient, his  fam- 


PYOPNEUMOTHORAX. 

LARGE  PULMONARY  CAVITY. 

History  of  pleurisy,  interspaces 

Immobile,  flat  chest,  spaces  de- 

motionless and  bulging, 

pressed. 

Apex  beat  displaced, 

Apex    beat    normal. 

Vocal    fremitus    less.      Percus- 

More  fremitus. 

sion  note  full  and  deep. 

Tympanic  or  cracked  pot. 

Outline      of      dullness      follows 

Wintrich's  change  of  sound. 

change    of    posture. 

Vesicular  sounds  and  vocal  res- 

Vesicular sounds  and  vocal  res- 

onance present. 

onances  absent, 

Bronchial  sound,  increased. 

Amphoric    sound    if    air    passes 

Cracliling,     gurgling,     cavernous 

opening, 

or  amphoric  sounds,  pec- 

Coin     sound      and      succession 

toriloquy. 

splash. 

No  bell-tympany  or  splash. 

ily  liistory,  occupation,  habitation,  the  physical 
signs  of  localized  pulmonary  disease  in  one  apex, 
slight  cough,  fever,  wasting,  hectic,  hemoptysis, 
brilliancy  in  evenings  and  night-sweats  are  all 
ominous;  but  in  these  modern  days  the  diagnosis 
is  made  solely  by  the  microscope.  The  X-ray  is 
of  value  only  in  advanced  stages.  The  rise  of 
temperature  following  the  hypodermic  injection 
of  tuberculin  is  highly  significant. 


184  THE   DISEASES    OF   THE   RESPIRATORY    ORGANS. 

Pkogn'Osis. — Bad  indications  are  the  acnteness 
of  the  attack,  rapidity  of  its  progress,  deficient 
resisting  power  of  the  patient,  high  and  persistent 
fever,  hectic,  night-sweats,  the  presence  of  many 
tnbercle  bacilli  and  streptococci  in  the  sputa,  soft- 
ening and  cavity  formation,  comj)lications,  inabil- 
ity to  take  and  ntilize  needed  food,  disposition  to 
substitute  alcohol  for  food,  age  below  or  at 
puberty,  bad  hygienic  environment  and  poverty. 

Death  may  occur  from  intercurrent  disease, 
nephritis  with  hydremia,  endocarditis,  hemor- 
rhage, angina  pectoris,  but  usually  is  due  to  ex- 
haustion. The  course  is  most  varied;  one  of  my 
patients  died  in  four  days,  while  many  survive  for 
many  years.  Anders  gives  the  average  as  three 
years. 

Liability. — The  liability  to  tuberculosis  is  uni- 
versal. 

I  have  known  the  strongest  men,  living  the 
healthy  life  of  farmers,  without  an  instance  of  the 
disease  in  their  ancestry  as  known  for  several 
generations,  to  become  tuberculous  within  a  year 
from  the  day  they  married  consum.ptive  wives. 
Nevertheless  the  predisposition  to  the  disease 
varies,  and  some  are  more  liable  to  contract  it 
than  others.  This  is  not  always  a  question  of 
strength,  as  the  strongest  of  men  may  succumb  to 
the  attack  of  the  bacillus  when  weaker  men  es- 
cape.    When  a  student  in  Cleveland,  one  of  my 


CHROXic  PHTHISIS.  186 

classmates,  Lee  Heavner  of  West  Virginia,  a 
great  powerful  man,  of  faultless  habits,  without 
preliminary  ailment,  was  seized  with  tubercular 
phthisis  and  succumbed  within  the  year.  Xone 
of  his  classmates,  exposed  to  the  same  influences, 
occupying  the  same  room,  were  affected.  His 
family  was  well  known  to  be  consumptive.  In 
this  case  the  evidence  seemed  to  be  conclusive  that 
there  was  a  hereditary  predisposition  and  not  an 
infection  through  residence  in  an  infected  house, 
for  the  man  was  not  living  at  home  when  the  dis- 
ease attacked  him. 

In  many  other  cases  the  alleged  inheritance  is 
really  a  contagion,  the  patient  being  attacked 
while  occupying  the  house,  room,  or  bed,  in 
which  a  tuberculous  person  is  or  has  been.  Flick 
has  accumulated  much  evidence  showing  that  tu- 
berculosis haunts  certain  houses,  attacking  succes- 
sive families  dwelling  therein.  If,  as  is  claimed,  a 
consumptive  emits  billions  of  tubercle  bacilli  each 
twenty-four  hours,  it  is  easy  to  see  how  a  house 
becomes  affected.  The  most  remarkable  cases  of 
galloping  consumption  I  have  ever  known  were 
in  four  men  who  occupied  a  very  small  bedroom. 
One  became  tuberculous  and  spit  all  over  the 
floor,  walls  and  bed.  Two  of  the  others  were 
attacked,  and  died,  one  in  six  weeks,  the  other  in 
four  days.  The  lungs  were  crowded  with  tuber- 
cles to  an  incredible  extent. 


186  THE   DISEASES   OF  THE   RESPIRATORY   ORGANS. 

The  liability  to  tuberculosis  is  greater  in  the 
children  of  consumptives,  in  scrofulous  children, 
in  those  who  are  liable  to  epistaxis  during  child- 
hood, in  those  who  are  debilitated  through  dis- 
ease and  faulty  hygienic  environment,  the  rickety, 
cyanotic,  etc.  The  liability  is  also  increased  by 
the  occurrence  of  typhoid  fever,  measles,  whoop- 
ing-cough, and  any  form  of  pneumonia. 

Contagion  is  favored  by  crowding  together 
numerous  persons,  in  badly  ventilated  places  such 
as  asylums,  jails,  factories,  and  sweat-shops,  es- 
pecially when  poor  feeding  and  depressing  influ- 
ences are  at  work.  The  milk  and  flesh  of  tuber- 
culous cattle  carry  bacilli,  and  domestic  animals, 
are  frequently  to  be  blamed  with  the  infection  of 
their  owners. 

In  the  great  majority  of  cases  the  attack  may 
be  credited  to  the  inhalation  of  the  bacilli  given 
off  with  the  sputa  of  consumptives.  Less  fre- 
quently the  other  excreta  are  the  source  of  infec- 
tion. While  the  bacilli  live  for  an  unknown 
period  outside  the  body,  the  influences  fatal  to 
them  probably  balance  their  reproduction,  since 
the  proportion  of  the  human  race  that  becomes 
tuberculous  does  not  perceptibly  increase.  It  is 
therefore  evident  that  if  care  were  taken  to  de- 
stroy all  the  excreta  of  all  tuberculous  patients  an 
end  would  be  put  to  the  affection  in  time. 

Teeatment. — Consumptives  should  use  a  por- 


CHRONIC    PHTHISIS.  187 

table  cuspidor,  of  which  there  are  several  available 
forms  in  the  market.  The  sputa  should  be  burnt; 
chemical  disinfectants  are  less  certain.  The  feces 
and  urine  should  be  passed  into  a  vessel  contain- 
ing freshly  made  whitewash,  and  allowed  to  stand 
an  hour  before  emptying.  When  the  patient  va- 
cates his  apartments,  by  death  or  otherwise,  the 
disinfection  should  be  as  thorough  as  possible,  the 
most  satisfactory  method  being  to  burn  the  house 
down.  For  this  reason  it  is  advisable  that  such 
cases  live  in  inexpensive  houses,  of  wood  or  of 
corrugated  iron,  with  the  simplest  of  furniture. 

'No  person  should  occupy  the  same  bed  as  the 
consumptive,  and  the  children  of  such  patients 
should  be  taken  to  another  residence  if  possible. 
They  should  be  systematically  hardened,  by  cold 
baths,  salt  rubbing,  and  open-air  life,  carefully 
regulated  exercise,  scientific  feeding  and,  in  a 
word,  all  the  resources  of  modern  hygiene.  Chil- 
dren predisposed  to  consumption  are  apt  to  be 
very  "nice"  about  their  eating.  They  should  be 
taught  systematically  to  discourage  the  eccentrici- 
ties of  taste,  and  to  eat  everything.  Too  often 
these  peculiarities  are  encouraged  by  the  mother, 
under  the  idea  that  they  are  evidences  of  some 
sort  of  superiority  on  the  part  of  the  child.  The 
stomach  is  a  creature  of  habit  and  may  be  trained 
to  do  its  duty  as  readily  as  the  child  itself.  Es- 
pecially should  they  be  taught  to  eat  fats,  which 


188  THE   DISEASES    OF  THE   RESPIRATORY   ORGANS. 

such,  children  rarely  do.  At  first  the  fat  will 
cause  indigestion,  but  by  a  few  weeks'  persistence 
this  will  be  overcome  and  the  fat  will  be  relished. 
Similar  persistence  w^ill  subdue  the  dislike  for 
nearly  if  not  all  foods  at  first  not  relished,  and 
the  net  result  will  be  a  stomach  that  will  digest 
anything  its  owner  thinks  best  to  put  into  it;  a 
very  desirable  state  of  affairs.  I  have  tried  this 
method  on  myself  and  on  my  children,  and  speak 
from  personal  experience  when  I  say  that  it  can 
easily  be  done,  and  that  the  results  are  very  satis- 
factory. 

There  are  three  respects  in  which  the  choice  of 
a  climate  influences  the  patient,  whether  he  is 
already  a  consumptive  or  simply  predisposed  to 
that  disease.  First:  All  persons  gain  blood  in  an 
elevated  locality,  the  blood  becoming  richer  in 
red  cells  and  in  hemoglobin  in  high  altitudes.  I 
noticed  with  interest  the  brick-red  complexions  of 
all  the  inhabitants,  especially  the  children,  at 
Silver  Plume,  Colorado,  over  9,000  feet  above  the 
sea-level. 

Secondly:  All  persons  enjoy  better  health  and 
resist  the  attacks  of  disease  better  as  they  spend 
more  time  in  the  open  air.  Those  who  are  predis- 
posed to  tuberculosis  and  those  who  still  feel  ca- 
pable of  making  a  fight  for  their  lives  should  ar- 
range their  affairs  so  as  to  keep  in  the  open  air  as 
much  as  possible.    There  are  advantages  even  in 


CHRONIC   PHTHISIS.  189 

the  noble  i^rofession  of  the  tramp,  even  in  that  of 
the  book-agent.  That  climate  is  best  for  each  pa- 
tient in  which  he  or  she  can  spend  the  most  time 
in  the  open  air.  This  embraces  the  consideration 
of  heat  and  cold,  moisture  and  dryness,  sunshine 
and  shade,  etc.  An  equable  climate,  without  sud- 
den changes  or  extreme  heat  or  cold,  with  a  maxi- 
mum of  sunny  days,  with  a  dry  atmosphere  and  a 
free  circulation  of  air,  is  usually  preferred.  A 
thickly  wooded  country  would  be  objectionable 
because  there  would  be  little  circulation  and  much 
dampness.  Taken  altogether,  the  western  slopes 
of  the  Eocky  Mountains  offer  the  most  generally 
suitable  locations,  the  patient  following  them 
south  into  Mexico  as  the  fall  approaches,  and 
north  into  Idaho  as  the  summer  advances. 

Third:  Individual  preferences  and  peculiarities 
must  be  consulted.  Broadly  speaking,  mankind  is 
divided  into  two  classes,  the  mountaineers  and 
seamen.  Some  improve  the  moment  they  reach  the 
mountains  and  languish  at  the  seashore,  while 
others,  perhaps  in  the  same  family,  find  the  sea- 
side suits  them  and  do  badly  in  the  elevated  re- 
gions. Along  the  Atlantic  coast  there  are  many 
persons  formerly  consumptive  who  have  found 
health  there  and  have  wisely  made  it  their  perma- 
nent home.  Others  are  to  be  found  in  the  Adiron- 
dacks,  in  Minnesota,  Colorado,  Southern  Califor- 
nia, Arizona,  Texas,  the  Gulf  Coast,  Florida,  the 


190  THE   DISEASES    OF   THE   RESPIRATORY    ORGANS. 

West  Indies,  Old  Mexico^  and  every  other  locality 
that  has  as  yet  been  exploited  as  a  "cure"  for 
consumption.  And  in  every  one  of  these  places 
are  the  graves  of  nnnnmbered  dead,  who  have 
been  allured  by  the  glowing  reports  of  the  first 
enthusiasts  who,  finding  health  there,  jumped  at 
the  hasty  conclusion  that  their  experience  would 
be  that  of  all  who  followed  them.  Beyond  the 
principles  laid  down  above,  there  is  absolutely  no 
benefit  to  be  obtained  from  any  climate,  and  the 
selection  must  be  made  on  personal  grounds  en- 
tirely. It  has  not  as  yet  been  shown  that  any 
climate  is  specifically  curative,  or  that  any  atmos- 
phere has  in  it  any  element  fatal  to  the  tubercle 
bacillus,  or  is  deficient  in  any  element  necessary 
to  its  vitality. 

The  only  rule  deducible  from  our  experience  is 
that  no  person  should  be  sent  to  any  place  that  has 
acquired  a  reputation  for  the  cure  of  consump- 
tion. The  reasons  are,  the  pollution  of  the  air  by 
the  bacteria  from  the  crowds  of  consumptives, 
the  lack  of  proper  accommodations  from  the  same 
cause,  and  the  depressing  influence  of  seeing 
around  one  these  fellow-sufferers,  all  animated 
by  the  hope  of  a  cure,  and  most  of  them  evidently 
deceiving  themselves.  For  the  marvelous  hope- 
fulness of  the  consumptive  does  not  take  in  his 
consumptive  neighbor;  and  when  one  sees  the 
others  equally  hopeful  and  yet  failing  every  day. 


CHRONIC   PHTHISIS.  191 

the  pessimistic  thought  is  apt  to  intrude,  that  he 
also  has  been  deceiving  himself,  and  pessimism 
is  a  fatal  symptom  in  a  consumptive. 

When  the  location  has  been  selected,  the  pa- 
tient must  find  some  suitable  occupation;  and  this 
is  a  matter  of  much  importance.     He  ought  to 
have  a  productive  one,  as  he  should  be  encour- 
aged to  look  upon  himself  as  a  normal,  self-sup- 
porting member   of   the   community,   not   as   an 
invalid.     Indeed,  it  is  hard  to  say  how  far  this 
principle  can  be  carried  with  advantage,  as  even 
advanced  cases  have  responded   favorably  to   it. 
By  rule,  the  patient  should  keep  quiet  and  in 
bed  while  the  temperature  is  up,  and  do  his  exer- 
cising in  the  morning,  when  the  fever  is  down. 
Fatigue  is  also  to  be  avoided,  as  the   tubercle 
bacilli  more  readily  overcome  the  resistance  of  the 
body  when  it  is  exhausted  by  any  cause.    Fatigue 
is  therefore  apt  to  be  followed  by  a  development 
of  the  malady.    The  minute  care  that  follows  the 
patient  about,  checks  him  whenever  he  has  had 
exercise  enough,  throws  a  shawl  over  him  when 
heated  or  as  the  air  grows  cooler,  keeps  him  in  bed 
during  the  febrile  period,  and  thus  prevents  tak- 
ing cold,  becoming  fatigued  and  other  possible 
causes  of  backsets,  has  its  place  especially  with 
advanced  cases,  and  that  numerous  class  that  has 
no  sense  of  its  own  to  exercise.     N'evertheless,  in 
this  class  we  can  but  rarely  look  for  a  cure.     In 


192  THE  DISEASES   OF   THE  RESPIRATORY   ORGANS. 

the  majority  the  result  of  our  efforts  is  simply 
that  prolongation  of  life  and  alleviation  of  its 
miseries  that  seem  so  much  to  the  doctor  and  so 
little  to  the  patient. 

Though  this  method  of  management  is  the- 
oretically correct,  so  strong  is  the  influence  of 
suggestion  that  some  will  improve  by  disregard- 
ing every  precaution  and  deliberately  forgetting 
that  they  are  invalids.  They  go  out  every  day, 
rain  or  shine,  fever  or  no  fever,  persist  in  wan- 
dering over  the  mountains,  eat  all  sorts  of  food 
with  an  out-door  appetite,  and  by  the  force  of 
will,  of  rousing  the  vital  powers,  and  the  influ- 
ence of  hope,  they  actually  recover,  the  wounded 
lung  cicatrizes,  and  they  live  out  their  allotted 
time.  These  are  the  exceptional  cases.  For  one 
that  is  thus  cured,  twenty  are  killed  by  the  same 
means.  If  the  patient  be  of  the  timorous  class 
that  dreads  death  and  wants  to  cling  to  every  day 
that  he  may  be  kept  alive,  it  is  best  to  adopt  the 
painstaking  plan;  and  this  is  the  only  one  for  the 
advanced  cases,  for  the  weakly  and  indolent,  and 
for  those  who  are  not  likely  to  follow  up  the 
active  plan  with  energy  and  intelligence.  But 
for  those  brave  souls  that  will  only  give  up  when 
life  is  extinct,  who  will  die  fighting  if  die  they 
must,  and  will  take  any  chance,  small  though  it 
may  be,  rather  than  sit  still  and  wait  for  death,  the 
active  plan  is  preferable. 


CHRONIC   PHTHISIS.  198 

The  diet  of  the  consumjDtive  should  be  rich  in 
nitrogenous  articles,  care  being  taken  that  they 
are  completely  digested.  There  is  a  certain  an- 
tagonism between  uricemia  and  consumption,  and 
the  meats  that  produce  uric  acid  protect  against 
the  graver  affection.  Milk  is  most  useful  if  from 
cows  certainly  not  themselves  infected.  Eggs, 
fish,  oysters,  rare  meats,  with  acid-pepsin  to  aid 
digestion,  are  of  special  value.  But  these  are  not 
to  be  used  to  the  exclusion  of  other  food.  The 
most  infinite  variety  of  foods  gives  better  results 
than  any  limited  diet. 

The  question  of  alcohol  has  been  fought  over 
for  many  years,  but  the  view  now  held  is  that  this 
agent  does  not  in  any  manner  aid  the  patient, 
while  it  favors  the  occurrence  of  fibrosis  and  the 
destruction  of  the  pulmonary  cells.  Its  inter- 
ference with  nutrition  is  beyond  question,  while 
it  destroys  the  appetite,  the  patient  tending  to 
gradually  substitute  alcoholic  beverages  for  food. 
I  never  use  alcohol  in  the  treatment  of  consump- 
tives and  rarely  in  any  other  affections. 

The  use  of  nuclein  in  tuberculosis  is  based  on 
the  following  consideration:  Leucocytosis,  the 
multiplication  of  the  white  blood  cells  beyond  the 
normal  number,  takes  place  in  almost  every  dis- 
ease of  bacterial  origin,  with  the  exception  of 
tuberculosis.  All  these  other  microbic  affections 
are  self-limiting,  again  excepting  tuberculosis.   Is 


194  THE  DISEASES  OF  THE  RESPIRATORY   ORGANS. 

there  any  connection  between  these  two  facts? 
Metschnikoff,  in  his  celebrated  observations  on 
the  phagocytic  action  of  the  white  cells,  con- 
cluded that  these  bodies  played  the  part  of  an 
armed  force,  ready  to  combat  any  intruding  micro- 
organism. Buchner  followed  with  the  observation 
that  the  blood-sernm  exclusive  of  the  cellular  ele- 
ments could  destroy  disease  germs.  Finally 
Vaughan  announced  that  by  the  administration 
of  nucleinic  acid  the  number  and  activity  of  the 
leucocytes  could  be  increased. 

While  the  evidence  is  strong  in  favor  of 
nuclein  when  given  by  the  mouth,  it  seems  wiser, 
in  administering  an  agent  whose  action  is  so 
nearly  if  not  altogether  a  vital  one,  to  take  no 
chances  on  its  being  destroyed  by  the  gastric 
juice,  but  to  give  it  by  the  more  direct  or  hypo- 
dermic method. 

It  is  uncertain  how  much  nuclein  can  be  given 
with  advantage,  but  I  have  administered  it  in  doses 
of  ten  to  fifteen  minims  once  a  day.  My  results 
are  encouraging  and  the  reports  from  my  cor- 
respondents enthusiastic,  but  as  yet  the  method 
has  not  been  tried  and  judged  with  the  thorough- 
ness that  is  required  by  modern  medical  science. 
All  I  can  say  at  present  is  that  I  recommend  its 
use  in  all  cases  of  tuberculosis. 

This,  with  reconstructive  tonics,  preferably  the 
arsenates  of  iron,  quinine  and  strychnine,  is  the 


CHRONIC   PHTHISIS.  195 

only  direct  treatment  I  have  to  recommend.  The 
various  forms  of  tuberculin  have  all  failed  to  es- 
tablish their  efficacy,  and  have  less  in  their  favor 
theoretically  than  nuclein.  The  reports  from 
Trudeau  indicate  that  no  more  is  to  be  said  on 
behalf  of  the  various  serums  tested  at  his  sana- 
torium. Many  capable  workers  are  running  out 
the  possibilities  in  these  lines,  and  it  may  be  that 
they  will  ultimately  hit  upon  something  of  more 
practical  utility;  but  at  present  this  is  still  "in 
the  air/' 

The  endeavor  to  destroy  the  bacilli  in  the  body 
by  chemical  germicides  has  resolved  itself  into 
the  use  of  creosote  and  its  derivatives,  especially 
guaiacol.  Out  of  many  cases  treated  with  these 
agents  a  few  have  been  cured.  These  have  been 
individuals  who  exhibited  a  remarkable  tolerance 
of  the  drug,  and  very  large  doses  were  given  for 
long  periods,  until  the  patient  was  saturated  with 
it.  One  woman  thus  treated  smelt  like  a  ham 
and  her  skin  was  the  color  of  drief  beef.  Few 
stomachs  can  bear  these  large  doses  of  creosote 
and  guaiacol,  but  oleo-creosote,  the  carbonates  of 
creosote  and  guaiacol  and  other  derivatives  have 
proved  more  agreeable.  Whether  they  are  as 
effective  also,  I  am  not  quite  sure;  but  I  have 
obtained  excellent  results  from  them  in  some 
cases,  pushing  the  doses  up  to  the  limit  of  tolera- 
tion; for  if  benefit  is  to  be  expected  from  a  germi- 


196  THE   DISEASES   OF   THE   RESPIRATORY   ORGANS. 

cide  it  should  be  given  to  bring  the  body  tinder  its 
influence  as  quickly  as  possible,  to  attain  such  a 
degree  of  saturation  as  will  render  it  impossible 
for  the  bacillus  to  live  in  it. 

The  most  potent  agents  I  have  yet  found  are 
the  sulphocarbolates.  The  discovery  of  their  use- 
fulness was  accidental.  I  had  reason  to  fear  that 
by  swallowing  sputa  a  patient  would  infect  his 
intestinal  canal,  and  to  prevent  this  I  gave  him 
zinc  sulphocarbolate,  which  I  had  long  used  as  an 
intestinal  antiseptic.  With  the  disappearance  of 
odor  from  the  stools  the  fever  dropped,  the  appe- 
tite and  digestion  improved,  and  the  general  im- 
provement followed  that  is  seen  in  other  cases  of 
febrile  disease  when  intestinal  antisepsis  has  been 
produced.  For  three  years  this  patient  has  taken 
the  sulphocarbolate  of  lime,  forty  grains  a  day, 
and  in  that  time  she  has  never  missed  a  meal  or 
had  an  indigestion.  The  calcium  salt  was  chosen 
because  the  fragility  of  her  tissues  demanded  lime, 
and  it  agreed  with  her  stomach.  I  have  since 
made  the  sulphocarbolates  a  standard  prescription 
in  all  eases  of  consumption,  and  have  been  abun- 
dantly satisfied  with  the  results. 

Iodoform  is  a  remedy  that  has  been  recom- 
mended by  many  clinicians,  on  different  grounds. 
J.  Solis-Cohen  praises  its  general  utility,  affirm- 
ing that  he  had  obtained  more  benfit  from  it  than 
from  any  other  single  remedy.     It  is,  in  part  at 


CHRONIC   PHTHISIS.  197 

least,  eliminated  by  the  lungs,  favorably  affecting 
the  cough,  stimulating  the  absorbents,  and  possi- 
bly acting  in  some  degree  as  an  obstacle  to  the 
multiplication  or  to  the  activity  of  the  bacilli. 
There  is  an  unusual  tolerance  of  this  agent  in 
consumption,  and  I  have  given  from  five  to  twelve 
grains  daily  for  months  without  the  production  of 
iodism. 

Many  observers  have  noted  the  virtues  of  strych- 
nine as  a  general  tonic,  improving  the  appetite 
and  digestion,  checking  the  fever  and  the  night- 
sweats,  as  well  as  the  tendency  to  colliquative  dis- 
charges by  the  skin  or  the  bowels,  etc.  I  have 
found  it  decidedly  advantageous  to  give  strych- 
nine arsenate  gr.  1-30,  three  to  seven  times  daily. 

Fever  is  not  so  much  due  to  the  direct  efforts 
of  the  bacilli  as  to  the  absorption  of  septic  prod- 
ucts. It  is  necessary  therefore  to  keep  the  puru- 
lent matter  cleared  away  as  thoroughly  as  possi- 
ble. The  pulmonary  tract  may  be  cleared  out 
by  inhaling  the  fumes  of  boiling  vinegar  for  five 
minutes  or  more  every  night  just  before  retiring. 
This  removes  the  collected  secretions,  and  the 
patient  has  relief  from  the  cough  for  some  hours, 
perhaps  until  the  next  morning.  Advantage  may 
be  taken  of  this  to  try  to  reach  the  affected  tissues 
with  local  remedies  applied  by  the  atomizer.  I 
usually  employ  an  oil  atomizer  charged  with  a 
mixture  of  europhen  in  fluid  petrolatum,  one  part 


198  THE  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

to  eight,  and  spray  with  this  for  five  minutes. 
Some  few  patients  find  great  relief  from  inhaling 
the  fumes  of  burning  sulphur,  and  this  should  be 
of  great  value  as  a  germicide,  but  most  persons 
are  unable  to  bear  even  a  slight  inhalation  of  this 
irritant  gas. 

The  foregoing  treatment,  aimed  at  its  cause, 
generally  reduces  the  fever  to  a  safe  point;  so  that 
direct  treatment  of  this  symptom  is  not  often  re- 
quired. In  case  an  antipyretic  is  needed,  how- 
ever, from  five  to  ten  drops  of  guaiacol  may  be 
rubbed  into  the  skin,  in  the  clavicular  region. 
This  produces  so  decided  a  fall  of  temperature 
that  some  caution  should  be  exercised  in  its  appli- 
cation. Or,  five  grains  each  of  guaiacol  and 
piperazin  may  be  given  in  capsule  every  four 
hours.  The  reduction  of  the  temperature  in  this 
manner  is  more  decided  and  lasts  longer  than 
when  Memeyer's  pill,  quinine  alone  or  any  of  the 
synthetic  antipyretics  of  ihe  anilin  series  are  given 

The  cough  may  be  treated  on  general  princi- 
ples, giving  codeine,  the  cyanide  of  zinc,  cannabis, 
or  steam  inhalations  to  soothe  irritation;  emetin 
or  lobelin  to  stimulate  secretion;  sanguinarine 
to  arouse  sensibility  and  cause  retained  secretions 
to  be  ejected;  atropine  or  aspidospermine  to  allay 
dyspnea;  strychnine  and  cubebin  to  restrain  ex- 
cessive secretion,  etc.  The  uses  and  causes  of  a 
cough  should  not  be  forgotten  in  treating  it. 


CHRONIC   PHTHISIS.  199 

Indigestion^  diarrhea,  etc.,  cease  to  be  promi- 
nent symptoms  of  consumption  when  the  general 
treatment  advised  is  employed,  and  hence  I  have 
nothing  to  add  on  this  score. 

And  with  all  this  done,  what  is  the  net  result? 
What  hopes  can  we  hold  out  to  our  patient?  Will 
he  in  spite  of  it  all  simply  delay  his  steps  awhile, 
and  then  rejoin  that  innumerable  caravan  that  is 
steadily  marching  along  the  road  to  the  consump- 
tive's grave? 

We  are  entirely  too  gloomy  in  our  prognoses 
of  consumptives.  Whittaker  says  that  it  is  shown 
by  the  records  of  many  thousands  of  autopsies 
that  two-thirds  of  the  human  race  suffer  at  some 
period  of  their  lives  with  tuberculosis,  and  that 
one-half  of  these  examinations  show  that  the  dis- 
ease has  been  cured.  This  gives  a  general  mor- 
tality of  fifty  per  cent.  Admitting  the  correct- 
ness of  the  gentleman's  figures,  it  is  difficult  to 
get  away  from  his  conclusions. 

I  can  now  look  back  over  a  period  of  thirty 
years  spent  in  the  study  and  practice  of  medicine. 
I  have  attended  many  a  consumptive  to  the  grave. 
But  throughout  my  professional  life  I  have  seen 
cures;  at  first  not  admitted,  as  the  conviction 
was  so  strong  that  the  disease  was  incurable,  that 
the  diagnosis  was  denied  if  the  patient  recovered. 
This,  of  course,  effectually  "jugulated"  all  the 
chances  of  establishing  a  successful  method  of 


200  THE  DISEASES   OF   THE   RESPIRATORY  ORGANS. 

treatment.  But  since  the  discovery  of  the  bacillus, 
easily  determined  by  the  use  of  reagents  and  the 
microscope,  we  can  proceed  on  the  basis  of  cer- 
tainty as  to  diagnosis,  and  maintain  our  claims  of 
success.  And  this  enables  us  to  assert  that  our 
earliest  claims  were  well  founded,  and  that  con- 
sumption has  indeed  been  cured  many  times  when 
the  doctor  allowed  himself  to  be  'fluffed"  out  of 
the  results  of  his  labors. 

It  is  also  evident  from  this  retrospect  that  there 
has  been  a  progressive  improvement  in  the  re- 
sults, as  the  methods  and  the  skill  of  the  doctor 
improved  with  experience.  Cures  have  been  more 
frequent,  and  the  average  life  of  those  who  were 
not  cured  has  been  longer.  And  since  everyone 
must  expect  to  die  sometime,  the  importance  of 
this  latter  statement  is  greater  than  at  first  sight 
seems  obvious.  Let  it  be  understood  that  in  each 
case  the  prime  object  is  not  so  much  to  kill  a 
swarm  of  invading  micro-organisms,  or  to  restore 
a  diseased  organ  to  an  impossible  condition  of 
perfection,  a  return  to  the  statu  quo  ante  helium, 
as  it  is  to  best  utilize  and  promote  the  patient's 
remainder  of  vitality,  to  extend  his  life  and  ca- 
pacity to  work  and  enjoy  to  their  utmost  possi- 
bility. If  this  be  fully  comprehended  by  the  doc- 
tor and  his  patient,  the  problem  assumes  a  some- 
what different  aspect.  Many  a  valuable  life  has 
been  wasted  in  the  vain  attempt  to  win  an  utterly 


CHRONIC    PHTHISIS.  201 

impossible  "cure/'  when  under  proper  manage- 
ment the  patient  might  have  lived  to  the  full 
limit  of  his  expectancy. 

How  to  live  the  best  and  longest  with  tubercu- 
losis is  often  our  study.  In  this  is  involved  tjie 
proper  care  and  treatment  of  all  classes  of  cases, 
from  those  that  can  be  entirely  and  permanently 
cured  to  those  who  go  down  rapidly  to  the  grave. 

From  the  treatment  outlined  in  this  paper  the 
writer  has  had  better  success  than  from  any 
method  previously  employed.  The  improvement 
in  some  cases  is  almost  past  belief.  In  some,  the 
bacilli  in  the  sputa  grow  scarcer  at  each  successive 
examination  and  finally  disappear;  the  symptoms 
showing  a  corresponding  course.  In  others  the 
bacilli  decrease  until  very  few  remain,  but  these 
few  persist  obstinately.  No  case  in  three  years 
submitted  to  this  method  has  failed  to  improve 
very  much.  Oases  of  mixed  infection  have  re- 
ceived in  addition  such  treatment  as  was  indi- 
cated, Marmorek's  serum  for  streptococci,  cal- 
cium sulphide  for  staphylococci  and  other  infec- 
tious micro-organisms,  etc.  The  value  of  the  lat- 
ter agent  in  tubercular  infection  is  a  question  in 
which  I  am  deeply  interested,  but  which  I  am 
not  yet  ready  to  discuss. 


CHAPTER  XXXVI. 

CAMP  AND  SANATORIUM   TREAT- 
MENT OF  CHRONIC  PULMONARY 
MALADIES. 

It  has  been  shown  conclusively  that  exposure 
to  sunlight  is  destructive  to  the  tubercle  bacilli, 
while  it  increases  the  vital  resistance  of  the  pa- 
tient. Denison  says  that  when  cattle  are  confined 
to  stables  they  become  tuberculous,  but  when 
taken  from  their  stalls  and  sent  out  to  graze  on 
the  open  prairie  they  gradually  recover,  so  that 
tuberculosis  becomes  extinct  on  the  ranges. 

Local  tuberculosis  of  the  skin  has  been  treated 
by  exposure  to  the  actinic  rays  with  some  suc- 
cess. The  effect  has  been  attributed  to  the  ger- 
micidal action  of  the  chemical  rays,  just  beyond 
the  violet,  to  the  increased  supply  of  blood  thus 
attracted  to  the  skin,  and  to  the  effect  of  the 
light  upon  the  blood.  In  the  laboratories  light 
must  be  excluded  or  the  cultures  are  lost.  It  is 
obvious,  therefore,  that  the  climate  best  suited 
for  consumptives  is  that  where  they  can  enjoy 
the  most  sunshine. 

Kime  very  rationally  contends  that  to  secure 
the  benefits  of  sunlight  the  patient's  body  should 
be  exposed  to  it,  and  not  merely  his  clothes.    He 


CAMP   AND    SANATORIUM    I REATMENT,    ETC.  203 

has  demonstrated  that  when  concentrated  the 
actinic  rays  pass  entirely  through  the  human 
body,  with  sufficient  intensity  to  reproduce  a  pic- 
ture on  a  photographic  dr}^  plate.  The  skin 
offered  most  resistance,  the  muscles  less  and  the 
bones  the  least.  By  using  blue  light  a  large 
percentage  of  the  actinic  force  is  utilized,  with 
little  of  the  heat,  which  is  strongest  in  the  red 
rays.  Kime  is  in  doubt  as  to  whether  the  rays 
kill  the  tubercle  bacillus  directly  or  simply  by 
stimulating  phagocytosis;  but  in  skin  tubercu- 
losis he  is  positive  as  to  the  curative  action,  the 
malignant  ulcer  being  converted  into  a  simple 
one.  In  one  of  his  cases  three  treatments  of  ten 
minutes  each,  with  a  blue  lens  near  the  cautery 
point,  effected  a  cure  in  three  weeks. 

Abrams  reported  cures  of  tuberculous  lym- 
phatic glands  by  this  agent.  Whether  the  method 
will  prove  as  successful  in  the  treatment  of  pul- 
monary tuberculosis  remains  to  be  seen;  though 
the  early  reports  are  encouraging.  The  question 
is  most  important,  as,  if  the  advantages  of  cli- 
mato-therapy  can  be  thus  secured  at  any  place, 
its  benefits  may  be  extended  to  the  enormous 
majority  who  cannot  leave  their  homes. 

The  value  of  a  residence  in  elevated  regions 
lies  partly  in  breathing  the  rarefied  air.  This 
stimulates  the  respiratory  apparatus  and  devel- 
ops it,   so  that  mountaineers  are  noted  for  the 


204  THE   DISEASES    OF   THE    RESPIRATORY    ORGANS, 

fine  development  of  their  chests.  This  is  imitated 
in  the  pneumatic  cabinet,  which  the  patient  en- 
ters and  the  air  is  rarefied  by  an  exhanst  pump. 
This  is  said  to  be  a  very  effective  remedy  for  pul- 
monary hemorrhages,  but  at  the  best  it  is  but  a 
paltry  substitute  for  the  mountaineer's  life,  with 
its  sunlight,  pure,  cool  air,  exercise  in  climbing, 
with  the  consequent  appetite  and  digestion.  An 
hour  or  two  spent  in  the  cabinet  is  of  benefit, 
but  living  on  the  mountains  for  24  hours  of  each 
day  is  that  much  better. 

The  cabinet  permits  the  use  of  medicated  in- 
halations but  these  are  managed  easily  without 
it.  In  the  cases  where  I  have  employed  the 
fumes  of  burning  sulphur  I  have  been  surprised 
at  the  ease  with  which  patients  withstood  them. 
Personally  the  smallest  trace  of  the  fumes  in  the 
air  will  set  up  the  most  violent  coughing,  which 
will  last  long  after  leaving  the  room;  but  tuber- 
culous patients  will  breathe  with  comfort,  and 
absolutely  with  liking,  air  thick  with  the  gas. 
The  inhalations  generally  give  marked  relief,  and 
the  symptoms  are  ameliorated,  sometimes  for 
weeks  or  months  afterwards. 

The  great  value  of  Finsen's  light-cure  lies  in 
the  patient's  being  treated  at  his  home,  where  he 
is  under  the  doctor's  watchful  care.  In  the  vast 
majority  of  cases  this  is  the  first  essential.  Few 
men  or  women  know  how  to  live  hygienically. 


CAMP   AND   SANATORIUM   TREATMENT,  ETC.  205 

Still  fewer  do  it,  even  when  healthy.  In  chronic 
disease  of  the  lungs  the  regulation  of  the  life  is 
everything.  Fatigue  seems  always  to  be  followed 
by  a  renewal  of  the  malady,  as  if  the  little 
enemies  were  ever  ready  to  seize  a  favorable 
opportunity  to  renew  their  attacks.  A  lazy  in- 
door life  saps  the  vitality  also;  so  that  to  steer 
between  the  two  difficulties,  securing  the  maxi- 
mum benefit  of  out-door  exercise  and  avoiding 
fatigue,  requires  a  nicety  of  judgment  rarely  seen 
outside  of  the  medical  profession  and  not  too 
often  within  its  ranks. 

Then  again,  few  consumptives  know  how  to 
vary  their  clothing  with  the  changing  weather, 
how  to  get  the  greatest  benefit  from  their  food 
without  overtaxing  the  digestive  organs,  how  to 
train  the  stomach  properly;  in  a  word  how  to 
give  their  personal  habits  that  minute  and  in- 
telligent care  they  demand,  and  yet  not  become 
hypochondriacs  or  valetudinarians.  Is  it  not  all 
summed  up  by  saying  that  the  consumptive  must 
have  a  doctor  to  do  the  thinking  for  him,  in  so 
far  as  his  malady  is  concerned? 
.  I  have  said  that  the  best  climate  is  that  which 
affords  the  largest  proportion  of  sunshine.  Add 
to  this  the  benefit  of  mountain  air,  and  we  will 
find  what  we  seek  in  the  elevated  regions  of  the 
Eocky  Mountains,  along  their  entire  extent.  In 
summer   the   patient   can  go  north,   and   ascend 


206  THE  DISEASES   OF  THE  RESPIRATORY   ORGANS. 

higher  to  secure  coolness;  in  winter  he  must  go 
south,  or  descend  to  the  foot-hills.  In  Northern 
New  Mexico,  at  Aztec,  on  Las  Animas  river,  some 
consumptives  have  regained  health.  This  table- 
land is  about  6000  feet  above  the  sea;  it  is  cooled 
in  summer  by  the  breezes  from  snow-clad  moun- 
tains, and  protected  by  them  from  excessive  wind. 
The  winters  are  mild,  with  but  little  frost,  so 
that  with  the  aid  of  an  oil-stove  patients  can  live 
in  tents  the  whole  year.  The  soil  is  sandy,  drain- 
age good,  water  alkaline.  Fruits  of  all  kinds 
flourish  on  the  soil  watered  by  irrigation  (by 
private  ditches,  not  by  corporations).  The 
air  is  dry,  the  sandy  plains  extracting  the  mois- 
ture. No  great  rush  has  yet  occurred  to  this 
region,  so  that  it  is  as  yet  unpolluted. 

Arizona  is  well-suited  for  winter  residence,  but 
too  hot  for  summer.  Along  the  mountains  thence 
down  into  old  Mexico  can  be  found  many  ideal 
localities,  for  those  able  to  care  for  themselves 
and  secure  their  own  food.  Those  able  to  hunt 
can  find  game  in  abundance,  but  outside  the 
States  they  need  not  expect  hotels  or  American 
food.  For  those  who  can  endure  and  enjoy  the 
life  of  the  hunter  and  prospector,  health  is  to  be 
found  in  these  regions. 

For  the  delicate,  women  and  advanced  cases, 
it  is  wiser  to  go  where  the  comforts  of  civilized 
life  can  be  procured.     Florida,  our  new  island 


CAMP  AND  SANATORIUM  TREATMENT,    ETC.  307 

possessions  in  the  West  Indies,  Cuba  and  the 
Lesser  Antilles,  offer  many  eligible  locations, 
where  the  patient  may  enjoy  life,  obtain  its  lux- 
uries, accomplish  a  cure  when  still  possible,  and 
prolong  life  and  its  enjoyment  to  the  greatest 
extent  when  a  cure  cannot  be  secured.  In  other 
words,  a  residence  here  is  pleasant,  and  offers 
the  best  chances  for  a  cure  to  those  not  calculated 
for  the  rough  life  of  a  hunter. 

I  know  of  no  work  so  well  suited  as  a  guide- 
book than  the  one  written  by  my  old  friend  W. 
F.  Hutchinson,  under  the  title  of  "Under  the 
Southern  Cross."  Dr.  Hutchinson  for  many 
years  spent  the  winters  in  the  West  Indies,  Cen- 
tral or  South  America,  and  gave  in  this  book 
exactly  the  information  one  wants — where,  when 
and  how  to  go,  hotels,  prices,  pleasures,  dangers, 
how  to  dress,  etc.  The  book  was  published,  I 
believe,  by  Appletons. 

Porto  Eico  has  not  yet  been  exploited,  but 
deserves  especial  attention.  Its  hills  should  prove 
especially  suitable  for  the  winter  homes  of  in- 
valids, when  the  government  is  settled  and  roads 
built.  Probably  many  openings  for  the  profitable 
emplo3niient  of  convalescents  with  some  capital 
will  be  found  there. 

Eobert  Louis  Stevenson  sought  health  in  the 
islands  of  the  South  Pacific,  and  found  there  a 
grave.    Nevertheless,  he  undoubtedly  lived  longer 


308  THE  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

and  more  eomfortably  than  if  he  had  remained 
in  the  N'orth.  The  climate  of  the  Philippines  is 
hot  and  damp,  and  under  snch  influences  the 
disease  progresses  rapidly,  the  bacteria  multiply- 
ing fast.  But  there  are  many  islands  where 
eternal  spring  reigns,  and  if  one  can  hear  the 
isolation  the  conditions  are  most  favorable  to  a 
cure.  But — one  young  man  I  sent  there  returned; 
and  when  I  asked  him  if  he  knew  he  came  back 
to  die,  he  said,  "Yes,  but  I  would  rather  die  in 
God's  country  than  live  there." 

Some  persons  care  more  for  life  than  for  human 
society,  but  this  matter  should  be  considered  care- 
fully before  advising.  If  the  patient,  forewarned, 
chooses  life,  let  him  be  sent  to  seek  out  a  suitable 
place,  and  when  there  adopt  the  native  costume 
of  a  bracelet  or  two,  and  let  the  sun  exert  its 
full  power.  To  some  of  us  who  have  had  fifty  years 
of  not  overly  pleasant  experience  with  humanity,  a 
Crusoe-like  life  on  an  ocean  inland,  with  a  ship- 
load of  books  and  other  necessaries,  would  not 
seem  so  undesirable. 

In  prescribing  a  camp  life  several  important 
objections  are  advanced  by  Von  Ruck,  such  as 
the  difficulty  of  obtaining  a  constant  supply  oi 
fresh  meats,  milk,  cream,  butter  and  other  stores, 
and  preserving  them,  keeping  the  camp  in  a 
sanitary  state;  taking  colds;  care  for  acute  attacks; 
shifting  location  with  the  season;  to  which  may 


CAMP  AND   SANATORIUM  TREATMENT,    ETC.  209 

be  added  the  questions  of  accessibility,  aid  in 
case  of  need,  and  the  intrusion  of  hostile  or 
curious  visitors.  In  truth,  camp  life  suits  but 
a  limited  class.  Even  so,  the  time  required  for 
a  cure  is  long,  by  no  means  limited  to  a  few- 
months;  and  when  one  has  been  cured,  there  will 
be  found  an  increased  liability  to  relapse,  when 
the  whilom  patient  returns  to  the  germ-laden 
air  of  civilization.  He  has  lost  his  immunization 
by  breathing  pure  air. 

Brooks  enumerates  the  following  essentials  for 
sanatoria  designed  for  consumptives: 

1.  There  should  be  a  good  southern  exposure. 

2.  The  soil  should  be  well  drained  and  pref- 
erably of  gravel.  It  is,  of  course,  essential  that 
the  foundations  should  be  dry. 

3.  There  must  be  free  access  of  sunlight. 

4.  The  "camp"  for  the  "Liege  und  Dauer- 
luftkur"  should  be  situated  in  the  open,  but  pro- 
tected from  the  north  and  east  winds.  Glass 
covers  to  the  verandas  are  not  necessary. 

5.  There  should  be  facilities  for  walking, 
preferably  through  woods,  and  if  possible  up  a 
slight  incline  from  the  sanatorium,  so  that  the 
homeward  journey  may  be  downhill.  There 
should  be  facilities  for  resting  at  easy  distances. 

6.  The  diet  should  be  most  carefully  regu- 
lated.    Feeding  should  be  slightly  in  excess,  but 


210  THE  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

the  food  should  be  well  selected,  nutritions,  tempt- 
ingly served  and,  of  course,  properly  cooked. 

7.  There  should  be  large,  airy,  individual 
sleeping  apartments,  affording  free  admission  of 
sunlight. 

8.  Every  patient  must  be  provided  with  an 
individual  spitting-cup,  and  forbidden  upon  pain 
of  immediate  dismissal  to  spit  anywhere  else. 

9.  There  should  be  withal  scrupulous  cleanli- 
ness, adequate  service  and  regular  disinfection. 
The  furniture  should  be  somewhat  severe.  Car- 
pets, brooms  and  hangings  have  no  place  in  a 
well  organized  sanatorium.  Cloths,  dampened 
with  antiseptics,  should  be  substituted  for  dust- 
ing. 

10.  There  should  be  a  routine  of  occupation, 
together  with  simple  diversions,  to  prevent  in- 
trospection. 

Much,  very  much,  could  be  said  in  favor  of  the 
sanatorium  for  consumptives.  The  constant 
supervision,  the  watchfulness  over  the  develop- 
ment of  the  malady  and  prompt  application  of 
suitable  remedies,  all  by  one  skilled  in  the  man- 
agement of  these  cases  by  daily  association  with 
the  patients,  all  this  is  of  incalculable  value. 

All  that  can  be  urged  against  the  sanatorium 
may  be  embraced  under  the  single  head  of  mis- 
management. If  the  destruction  of  sputa,  the 
daily  fumigation  of  the  living  rooms,  and  the 


CAMP  AND   SANATORIUM  TREATMENT,   ETC,  311 

other  measures  to  prevent  the  infection  of  the 
premises  and  reinfection  of  patients,  are  not 
carried  out  perfectly,  the  sanatorium  is  about  the 
most  dangerous  place  a  consumptive  could  find. 
A  patient  once  informed  me  that  every  morning 
the  servants  in  a  popular  "sanatorium"  could  be 
seen  mopping  up  the  sputa  from  the  halls, 
corridors  and  public  rooms! 

But  with  proper  management  such  an  institu- 
tion offers  the  very  best  chances  for  the  cure  of 
the  consumptive,  and  I  believe  the  per  cent  of 
cures  there  largely  exceeds  that  obtained  by  the 
camp  method.  Under  the  use  of  the  treatment 
herein  advised  the  bacilli  in  the  sputa  become 
fewer  until  they  disappear,  the  symptoms  and 
general  condition  of  the  patient  showing  cor- 
responding improvement.  Keep  him  in  the  san- 
atorium until  this  has  been  accomplished,  and 
he  has  been  taught  thoroughly  the  lesson  of  how 
to  care  for  himself;  then  send  him  to  the  camp. 

What  after  all  do  we  mean  when  we  speak  of 
d  cure  for  consumption?  The  bacilli  may  disap- 
pear, the  cavity  scar  and  contract,  the  disease 
become  obsolete.  But  tho  bacillus  always  lurks 
for  an  opportunity  to  reinfect  his  victim;  the 
predisposition  that  originally  determined  the  at- 
tack remains;  the  congenital  vulnerability  of  the 
tissues  has  not  changed.  Hence  the  patient  who 
has  been   cured   of  phthisis  still  remains  more 


212  THE   DISEASES    OF   THE   RESPIRATORY    ORGANS. 

liable  to  a  fresh  attack  than  the  person  who  has 
never  suffered  from  the  malady;  more,  even  yet, 
when  he  sojourns  in  a  bacteria-free  atmosphere 
he  loses  the  degree  of  immunity  he  has  enjoyed 
while  constantly  exposed  to  the  action  of  the 
bacilli,  and  when  he  returns  to  the  inhalation  of 
air  thickly  inhabited  by  them,  they  find  his  leu- 
cocytes unprepared  to  resist  their  onslaught. 
Hence  the  cured  consumptive,  who  wants  first  of 
all  to  continue  living,  should  find  an  open-air 
life  that  he  is  content  to  adopt  for  the  remainder 
of  his  days,  and  henceforth  eschew  the  'iDusy 
haunts  of  men."  There  must  be  no  hankering 
for  the  flesh-pots  of  civilization;  he  must  be  a 
solitary  wanderer  on  the  face  of  the  earth  the  rest 
of  his  days. 


CHAPTER  XXXVII. 
MANAGEMENT  OF  THE  PREDISPOSED 

One  of  the  most  serious  problems  before  the 
physician  is  the  care  of  persons  not  yet  consump- 
tive but  predisposed  to  become  so.  These  are 
the  weakl}''  children  born  of  consumptives;  of 
parents  weakly,  drunkards,  greatly  differing  in 
age;  in  families  where  the  new  baby  comes  regu- 
larly every  year  or  less.  The  children  are  frail, 
teething  late  and  badly,  walking  late,  the 
sclerotics  blue,  the  skin  thin  and  transparent,  the 
veins  showing  through,  under-sized,  precocious  in 
studies  and  too  weakly  to  take  part  in  the  rougher 
games  of  their  companions,  subject  to  catarrhs, 
epistaxis  and  gastro-intestinal  attacks.  The  skin 
sometimes  has  a  soft,  greasy  feel,  and  emits  a 
catarrhal  odor.  The  eyelids  may  be  eczematous. 
The  chest  is  flat,  the  lung-power  below  the 
average. 

Some  of  these  children  suddenly  shoot  up  to 
unusual  height,  but  this  only  emphasizes  the  de- 
fective chest-capacity.  They  are  usually  very 
nice  about  eating,  liking  few  things,  avoiding  fat 
and  coarse  vegetables.  Some,  however,  are  gross, 
the  face  pimply,  the  neck  seamed  with  the  scars 
of  glandular  suppuration,  the  habits  glutonous. 


314  THE  DISEASES   OF   THE   RESPIRAPORY   ORGANS. 

with  indigestion,  biliousness,  and  uricemia  habitu- 
ally. 

Very  rarely  the  florid  type  develops,  with  a 
complexion  whose  rich  olive  and  high  color  has 
a  brilliancy  that  is  wonderful.  These  people 
generally  get  the  reputation  of  using  cosmetics, 
or  "eating  arsenic,"  to  explain  the  unnatural 
beauty  of  the  skin.  One  remarkable  case  of  this 
variety  died  of  Pott's  disease;  two  others  are 
married,  mothers,  and  seem  to  have  safely  passed 
the  dangerous  period.  All  were  girls.  I  have 
never  seen  or  heard  of  a  male  case  of  this  de- 
scription. 

I  have  always  looked  upon  the  essential  point 
of  this  predisposition  to  phthisis  as  being  a  de- 
ficiency of  lime,  the  element  to  which  the  cells 
of  the  body  owe  their  strength.  If  the  lime  is 
deficient  the  cells  are  fragile,  they  break  down 
easily,  the  skin  breaks  on  slight  irritation  or  ex- 
posure to  cold  or  wet;  the  bones  ossify  slowly, 
the  teeth  are  slow  in  erupting  and  decay  soon. 

It  has  been  noted  that  -consumptives  rarely 
have  good  teeth.  I  have  also  noted  that  never 
once  in  over  30  years'  practice  have  I  seen  a  case 
of  cervical  adenitis  in  a  person  with  sound  teeth; 
so  that  I  have  learned  to  look  on  the  decaying 
teeth  as  an  open  door  of  which  tubercle  bacilli 
often  avail  themselves.    The  tonsils  form  another 


MANAGEMENT  OF  THE   PREDISPOSED.  215 

open  door;  and  in  their  crypts  may  be  found  the 
original  site  of  many  a  tubercular  invasion. 

The  deficiency  of  lime  is  not  due  to  its  scarcity 
in  the  food  or  drink,  for  this  element  is  often  in 
excess  in  hard  waters,  and  is  present  in  every 
ordinary  meal  in  sufficient  proportion  for  the 
bodily  needs.  The  difficulty  is  in  its  assimilation. 
This  may  be  partly  remedied  by  giving  an  excess 
of  lime  with  the  food,  or  by  giving  this  element 
in  the  most  manageable  form.  Experience  has 
shown  that  while  a  large  proportion  of  fat,  lime, 
iron,  etc.,  passes  through  the  alimentary  canal  and 
is  ejected  in  the  feces,  the  larger  the  quantity 
swallowed,  the  more  will  be  absorbed.  If,  for 
instance,  one  grain  of  iron  be  given  daily,  but 
one-tenth  of  a  grain  may  be  absorbed,  but  if  ten 
grains  be  given  one-tenth  of  this,  or  one  grain, 
will  be  taken  up. 

So  with  lime.  Give  a  superabundance  of  it, 
preferably  as  lactophosphate,  the  form  experience 
has  shown  to  be  most  easily  dissolved  in  the  body- 
fluids.  Let  the  child  be  taught  to  suck  soft  bones 
of  young  animals,  and  chew  off  as  much  of  them 
as  possible.  Powdered  bone  would  doubtless  also 
be  useful  if  it  could  be  procured  at  a  reasonable 
price.  Marrow  on  toast  or  in  soup  is  usually 
relished  by  any  one.  More  lime  will  be  absorbed 
if  given  in  numerous  small  doses  than  in  a  few 
large  ones.    A  granule  of  calcium  lactophosphate, 


216  THE  DISEASES   OF  THE   RESPIRATORY   ORGANS. 

0.01  (gr.  1-6)  every  half-hour,  does  more  good 
than  0.3  (gr.  v)  thrice  daily. 

I  have  many  times  noted  the  good  effect  on 
such  delicate  infants  of  daily  inunctions  with  oil. 
It  seems  reasonable  that  a  thin  animal  oil  will 
be  more  readily  taken  up  by  the  skin  and  utilized 
than  a  thick  or  vegetable  grease;  so  that  cod-liver 
oil,  lard  oil  or  goose-grease  is  usually  recom- 
mended. They  may  be  rendered  inodorous  by 
adding  a  little  eucalyptol  or  any  volatile  oil.  The 
inunctions  should  be  kept  up  throughout  the 
winters  and  as  long  as  the  child  appears  to  require 
them.  For  older  patients  a  woolen  undershirt 
may  be  saturated  with  the  oil  and  covered  with 
oiled  silk  to  protect  the  outer  clothes. 

Even  more  important  is  the  regime  by  which 
the  child  is  strengthened,  its  power  of  assimilat- 
ing the  food-elements  increased,  and  the  tissues 
rendered  more  resistant  to  morbific  influences. 
The  diet  should  be  carefully  regulated  to  the 
needs,  and  the  child  taught  to  eat  all  varieties  of 
wholesome  food.  Dislikes  are  soon  overcome  by 
having  the  child  eat  one  very  small  morsel  of  any 
food  it  dislikes,  or  that  it  does  not  digest  readily, 
at  every  meal.  Especially  should  it  be  thus 
trained  to  eat  fats  of  every  description.  A  well- 
trained  stomach  is  the  most  secure  form  of  life- 
insurance. 

Hot  salt  baths  keep  the  skin  in  good  order. 


MANAGEMENT    OF   THE   PREDISPOSED.  217 

and  bring  the  blood  to  the  surface  for  aeration. 
These  may  be  gradually  replaced  by  dry  rubbings, 
with  towels  dipped  into  brine  and  dried,  and  in 
midsummer  the  cold  bath  may  be  begun.  This 
should  be  looked  upon  as  strictly  a  therapeutic 
measure,  not  a  means  of  purification.  The  ideal 
cold  bath  is  a  quick  plunge,  shower  or  douche,  of 
momentary  duration,  a  quick  in-and-out-again, 
followed  by  brisk  rubbing  or  slapping  to  bring 
about  strong  reaction.  If  commenced  in  mid- 
summer the  baths  may  safely  be  continued  the 
year  around. 

The  effect  is  to  increase  oxygenation,  stimu- 
late a  more  active  circulation,  put  the  skin  in  a 
healthy  condition,  and  by  accustoming  it  to  cold 
render  the  patient  less  susceptible  to  catching 
cold.  The  sense  of  strength  and  well-being  fol- 
lowing the  cold  plunge  stimulates  the  child  to 
greater  physical  activity,  and  arouses  the  desire 
for  free  out-door  sport.  Moreover,  the  moral 
effect  is  by  no  means  unimportant.  No  child  at 
first  can  look  on  the  prospect  of  a  cold  plunge 
without  shrinking;  and  the  necessary  nerving 
one's  self  up  to  do  a  disagreeable  thing  because 
it  is  a  right  thing  to  do,  is  a  lesson  that  cannot 
be  learned  too  early  in  life. 

The  love  of  out-door  sports  and  occupations 
should  be  sedulously  cultivated,  and  yet  over- 
exertion as  sedulously  avoided. 


218  THE  DISEASES  OF  THE   RESPIRATORY   ORGANS. 

It  does  seem  as  if  a  most  useful  innovation  in 
our  school  system  would  be  the  making  of  do- 
mestic and  personal  hygiene  a  leading  study,  with 
practical  demonstrations,  and  such  exercises  as 
would  compel  the  pupil  to  really  comprehend  its 
meaning,  instead  of  a  perfunctory  topic  slurred 
over  once  a  week,  hastily,  that  the  pupil  may  get 
back  to  the  "classic"  topics;  the  real  value  of 
which  in  the  adult  life  is  incomparably  smaller. 
I  would  have  every  pupil  compelled  to  measure 
the  air-space  of  every  living  room  in  his  home, 
and  calculate  its  capacity  for  those  dwelling 
therein,  with  the  average  consumption  of  oxygen 
by  firelight  and  respiration;  the  ventilation;  test 
the  drinking  water;  examine  the  dust  microscop- 
ically and  bacteriologically;  examine  the  food 
chemically  and  microscopically — in  a  word  I 
would  make  him  comprehend  hygiene,  even  if  he 
never  learned  to  expand  the  binomial  or  even  to 
enumerate  the  Kings  of  England. 

Gymnastic  training  is  of  value,  to  expand  the 
chest  and  develop  the  body  symmetricallv;  but 
here  also  good  sense  must  rule.  Compare  on  the 
one  hand  the  consumptive  pugilist  Needham,  the 
only  man  who  ever  won  a  decision  in  the  ring 
against  Tom  Sayers,  and  the  fact  that  so  many 
trained  athletes  die  consumptives.  Needham,  by 
carefully  developing  his  powers  to  their  utmost 
healthy   limit,   accomplished   his   object.     Many 


MANAGEMENT   OF  THE   PREDISPOSED.  219 

athletes,  by  attempting  to  develop  themselves  be- 
yond their  natural  powers  fall  victims  to  the 
bacillus,  to  which  the  exhaustion  of  over-train- 
ing offers  a  most  excellent  opportunity. 

The  selection  of  an  occupation  should  be  made 
with  the  advice  of  the  physician.  I  am  too  well 
aware  of  the  execration  that  one  would  incur, 
by  advising  any  one  to  increase  the  number  of 
book-agents  or  peripatetic  dealers  in  anything, 
but  really  the  life  is  nearly  an  ideal  one  for  our 
ci-devant  predisposed-to-consumption,  who  yet  is 
not  prepared  to  take  to  the  hunter^s  or  prospect- 
or^s  life.  In  the  millennium  the  noble  profession 
of  the  tramp  may  become  respectable;  or  perhaps 
a  really  useful  form  of  tramping  may  be  devised, 
as  of  a  youth  I  once  knew  who  regained  health  as 
a  peripatetic  varnisher.  There  are  many  such 
things  that  would  make  a  workman  welcome  at 
the  farmhouse. 

Space  forbids  a  detailed  description  of  the  use- 
ful gymnastic  methods,  but  a  few  words  must  be 
said  of  respiratory  exercises.  Indian  club  swing- 
ing develops  the  chest-muscles  admirably,  and  has 
the  great  advantage  that  the  patient  can  have  the 
clubs  ready  for  a  five-minute  swinging  at  any 
hour,  and  many  times  a  day.  Always  stop  short  of 
fatigue,  and  use  the  clubs  for  short  periods  and 
but  few  times  a  day  at  first,  gradually  increasing 


220  THE  DISEASES   OF   THE   RESPIRATORY   ORGANS. 

the  length  and  frequency  of  the  exercises  as  the 
muscles  develop. 

Let  the  child  be  taught  to  breathe  through  the 
nose  alone,  to  hold  the  head  well  up,  and  to  slowly 
inhale  until  the  lungs  are  fully  distended,  five  or 
six  times  in  succession,  after  every  club-swinging. 
Carrying  something  balanced  on  the  head  is  an 
excellent  means  of  cultivating  an  erect  carriage, 
and  if  the  weight  be  gradually  increased  the 
spinal  supports  are  thereby  strengthened. 

Athletic  contests,  foot-ball,  wrestling,  boxing, 
etc.,  are  usually  to  be  avoided,  though  tennis,  golf, 
hand-ball  and  base-ball  are  useful.  The  rule  is 
that  the  youth  must  avoid  all  exercises  that  strain 
his  muscles,  or  try  them  to  the  limit  of  their 
capacity.  All  his  work  must  be  easily  within  this 
limit,  and  neither  his  own  ambition  nor  the  taunts 
or  persuasions  of  his  comrades  must  be  allowed  to 
provoke  him  to  the  full  display  of  his  strength. 
The  best  way  to  insure  this  is  to  teach  the  boy 
to  look  on  exercise  and  sport  as  means  for  attain- 
ing health  rather  than  as  exhibitions  of  prowess. 

For  these  subjects  a  residence  in  the  mountains 
is  always  advisable.  The  chest  develops  best  by 
breathing  the  thin  air  of  elevated  regions.  The 
blood  is  better  oxygenated  there,  so  that  the  brick- 
red  complexion  of  dwellers  over  8000  feet  above 
sea-level  excites  the  wonder  and  admiration  of 
lowlanders;  and  the  pure  air  offers  few  chances 


MANAGEMENT   OF  THE  PREDISPOSED.  221 

for  infection.  But  woe  to  the  mountain-bred 
youth  who  leaves  his  hill-tops  to  reside  in  the 
crowded  city.  He  is  doomed  to  the  consumptive's 
grave.  The  mountaineer's  pining  for  his  native 
hills  of  which  the  poet  has  so  often  sung  is  strictly 
physical  in  its  basis,  and  easily  comprehended  by 
the  pathologist. 


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